1. No category

SUPPLEMENT TO
JAAD
Journal of the
American
Academy of
Ô Dermatology
www.jaad.org
May 2014
/ Volume 70
/
Number 5
Poster Exhibit Task Force
The Posters Exhibit Task Force enhances the educational value of the
Academy Meetings by administering poster exhibits, poster discussion
sessions, and poster awards. Poster abstracts are solicited, blind reviewed,
and graded by peer review for selection as poster exhibits or poster
discussions. The Task Force develops guidelines and monitors posters for
quality educational content.
Task Force Members:
Tammie C. Ferringer, MD, FAAD, Chair
Khalid Ali Al Hawsawi, MD
Neal D. Bhatia, MD, FAAD
Diana Bolotin, MD, PhD, FAAD
Ivan Camacho, MD, FAAD
Gary Goldenberg, MD, FAAD
Alice B. Gottlieb, MD, PhD, FAAD
Shasa Hu, MD, FAAD
Jennifer Nguyen, MD, FAAD
Samuel John Reck, MD, FAAD
Lidia Rudnicka, MD, PhD
Jonathan I. Silverberg, MD
Molly Wanner, MD, FAAD
Sara Peterson, Staff Liaison
2015 Annual Meeting Program Submissions
Visit http://www.aad.org for information regarding program
participation for the 73rd Annual Meeting, March 20-24, 2015
in San Francisco, California.
SUPPLEMENT TO
JAAD
Journal of the
American
Academy of
Ô Dermatology
www.jaad.org
May 2014
/
Volume 70
Poster Abstracts
American Academy of Dermatology
72nd Annual Meeting
March 21-25, 2014
Denver, Colorado
/
Number 5
SUPPLEMENT TO
JAAD
Journal of the
American
Academy of
™ Dermatology
May 2014
www.jaad.org
/
Volume 70
/ Number 5
CONTENTS
Poster Abstracts
AB1
Pearls From the Posters: New and Noteworthy Research Finds
AB3
Pearls From the Posters: Top Case Studies and Reports
AB4
Acne
AB12
Aesthetic Dermatology
AB22
Aging/Geriatrics
AB27
Arts, History, and Humanities of Dermatology
AB28
Basic Science
AB34
Clinical Dermatology and Other Cutaneous Disorders
AB58
Connective Tissue Diseases
AB60
Dermatitis, Atopic
AB67
Dermatitis, Contact, Allergic and Irritant
AB71
Dermatopathology
AB75
Digital/Electronic Technology
AB77
Education and Community Service
AB79
Epidemiology and Health Services Administration
AB85
Genodermatoses
AB88
Hair and Nail Disorders
AB95
Immunodermatology and Blistering Disorders
AB99
Infection—Bacterial and Parasitic
Continued on page A4
Copyright Ó 2014 by the American Academy of Dermatology, Inc. The opinions or views expressed in this professional education supplement are those of the authors and do not
necessarily reflect the opinions or recommendations of the society, editor(s), or publisher.
Dosages, indications, and methods of use for products that are referred to in the supplement by the authors may reflect their clinical experience or may be derived from the
professional literature or other clinical sources. Because of the differences between in vitro and in vivo systems and between laboratory animal models and clinical data in humans,
in vitro and animal data may not necessarily correlate with clinical results.
Future citation agreement/How to cite abstracts from this supplement: Author(s) agree(s) that citations to poster abstracts published in the Journal
of the American Academy of Dermatology will adhere to the format of the examples given below, which clearly indicate that the cited item has been published in abstract
form.
Authors. Title of abstract (abstract). J Am Acad Dermatol 2014;70:AB page number.
Miyashiro D, Nunes A, Sanches JA. Erythroderma: Searching for diagnostic clues in a series of 164 patients. (abstract). J Am Acad Dermatol 2014;70:AB1.
J AM ACAD DERMATOL
MAY 2014
A3
Contents continued
AB106 Infection—Fungal
AB111 Infection—Viral
AB113 Internal Medicine Dermatology
AB121 Lymphoma, Cutaneous/Mycosis Fungoides
AB126 Melanoma and Pigmented Lesions
AB132 Nonmelanoma Skin Cancer
AB141 Pediatric Dermatology
AB150 Pharmacology
AB153 Photobiology, Phototherapy, and Photosensitivity Diseases
AB158 Pigmentary Disorders and Vitiligo
AB162 Psoriasis and Other Papulosquamous Disorders
AB192 Surgery—Cosmetic
AB194 Surgery—Dermatologic
AB197 Surgery—Laser
AB202 Wound Healing and Ulcers
AB205 Author Disclosures
AB253 Author Index
AB267 Subject Index
A4
MAY 2014
J AM ACAD DERMATOL
SUPPLEMENT TO
JAAD
Journal of the
American
Academy of
™ Dermatology
Editor Bruce H. Thiers, MD
Editorial Office
Detra Davis
Managing Editor
Journal of the American Academy of Dermatology
930 E Woodfield Road
Schaumburg, IL 60173
Phone: 847-240-1005; Fax: 847-240-0101
E-mail: [email protected]
Medical University of South Carolina
Charleston, South Carolina
Deputy
Editor
Dirk M. Elston, MD
Ackerman Academy of Dermatopathology
New York, New York
Anna Krueger
Editorial Assistant
Journal of the American Academy of Dermatology
930 E Woodfield Road
Schaumburg, IL 60173
Phone: 847-240-1706; Fax: 847-330-8907
E-mail: [email protected]
Associate Editors
Medical Dermatology
Jack L. Lesher, Jr, MD
Kenneth A. Katz, MD, MSc, MSCE
Mary C. Spellman, MD
Jeffrey M. Weinberg, MD
Dermatologic Surgery and
Oncology
Clifford Perlis, MD, MBe
Pediatric Dermatology
Julie Prendiville, MB, FRCPC
Past Editors
Dermatopathology
John C. Maize, Sr, MD
Founding Editor
J. Graham Smith, Jr, MD
Web Editor
Robert Dellavalle, MD, PhD, MSPH
Editors Emeritus
Richard L. Dobson, MD
Jeffrey D. Bernhard, MD
Assistant Editors
Medical Dermatology
Calvin O. McCall, MD
Brett Sloan, MD
James A. Solomon, MD, PhD
Stephen K. Tyring, MD, PhD
Dermatologic Surgery
and Oncology
George J. Hruza, MD, MBA
Dermatopathology
J. Andrew Carlson, MD
Tammie Ferringer, MD
Pediatric Dermatology
Kelly M. Cordoro, MD
Cyberdermatology Consultant
Daniel M. Siegel, MD, MS
Statistical Consultant
Clara Y. Kim, PhD
Editorial Board
Salvador Arias-Santiago, MD, PhD
April W. Armstrong, MD, MPH
Bryan Anderson, MD
Trisha Clarke Beute, MD
John Q. Binhlam, MD
Diana Bolotin, MD, PhD
Markus Braun-Falco, MD
Nooshin K. Brinster, MD
Patrick R. Carrington, MD
Zoe Diana Draelos, MD
Nananamibia Duffy, MD, MSCE
Laura K. Ferris, MD, PhD
David P. Fivenson, MD
Joel M. Gelfand, MD, MSCE
Camille E. Introcaso, MD
Nathaniel Jellinek, MD
Jonathan Kantor, MD, MSCE, MA
Matthew Kanzler, MD
Kevin Kia, MD
Nikki A. Levin, MD, PhD
J AM ACAD DERMATOL
Jason P. Lott, MD, MSHP
Omar Lupi, MD
Seth L. Matarasso, MD
David Najarian, MD
Julia R. Nunley, MD
Margot S. Peters, MD
Jack Resneck, Jr, MD
Neil Sadick, MD
Christopher R. Shea, MD
Donald Shenenberger, MD
Peter R. Shumaker, MD
Jerry K. L. Tan, MD
Yong-Kwang Tay, MD
Charles R. Taylor, MD
Curtis T. Thompson, MD
Kenneth Y. Tsai, MD, PhD
Jonathan Weiss, MD
Lorraine Young, MD
CME Planning Workgroup
Robert T. Brodell, MD
Kelly M. Cordoro, MD
Edward W. Cowen, MD, MHSc
Carlos Garcia, MD
Christopher Miller, MD
Desiree Ratner, MD
Brett Sloan, MD
Hensin Tsao, MD, PhD
Matthew Zirwas, MD
Pearls/Images
Giuseppe Argenziano, MD
Haines Ely, MD
Tammie Ferringer, MD
Kavita Mariwalla, MD
Giuseppe Micali, MD
Angela Yen Moore, MD
Alexander J. Stratigos, MD
Dermatoethics Consultations
Lionel Bercovitch, MD
Jane M. Grant-Kels, MD
MAY 2014
A5
PEARLS FROM THE POSTERS: NEW AND
NOTEWORTHY RESEARCH FINDS
P7805
Erythroderma: Searching for diagnostic clues in a series of 164 patients
Denis Miyashiro, MD, Hospital das Clınicas, S~ao Paulo, Brazil; Alice Nunes, MD,
Hospital das Clınicas, S~ao Paulo, Brazil; Jose Antonio Sanches, PhD, Hospital das
Clınicas, S~ao Paulo, Brazil
Background: Erythroderma is a severe syndrome with challenging etiologic
diagnosis. Despite histologic, immunophenotypic, and molecular analysis improvement, many cases remain as idiopathic ones.
Objectives: Analyze clinical, laboratory, and histologic findings of 164 erythrodermic
patients to find clues to the etiologic diagnosis and propose an adequate form of
investigation to facilitate the management of these patients. Survival data were
analyzed according to the etiologic diagnosis.
Methods: In a retrospective study performed at the Hospital das Clınicas, University
of S~ao Paulo Medical School (2007-2012) including 164 cases of acquired
erythroderma, clinical, laboratory, and histologic data were collected according to
a protocol of investigation. For qualitative variables, we the used chi-square or Fisher
exact tests, and for quantitative variables we used KruskaleWallis 1-way analysis of
variance.
Results: The median age was 55.7 years, with a male:female ratio of 1.98:1. The
atopic dermatitis group developed erythroderma in an earlier age (median, 22.5
years; P \.0001). Acute onset was associated with drug reactions (P ¼ .017) and
psoriasis (P ¼ .041). Psoriasis was the most frequent etiology (20.1%), followed by
eczema (18.9%), drug eruption (17.1%), Sezary syndrome (9.8%), atopic dermatitis
(8.5%), mycosis fungoides (6%), and other diagnoses (5.5%), represented by
pemphigus foliaceus, adult T-cell lymphoma, lichen planus, pityriasis rubra pilaris,
paraneoplastic erythroderma, and HIV-associated erythroderma. In 14% of the
patients, it was not possible to elucidate the cause of erythroderma. We did not
observe a significant statistical correlation between the groups for both clinical and
laboratory findings, except for high levels of immunoglobulin E in the atopic
dermatitis group. Pathologic examination was consistent with the final diagnosis in
73.9% of cases. Monoclonal T cell proliferation in the skin was observed essentially
in the mycosis fungoides and Sezary syndrome groups. At the last assessment, 65.2%
of patients were alive with evidence of disease, 26.8% were alive without disease,
and 7.9% had died with disease.
Conclusions: Erythroderma is a challenging syndrome with difficult diagnosis
approach and reserved prognosis. Young age and high immunoglobulin E levels
are associated with atopic dermatitis; acute onset is observed in drug eruptions and
psoriasis. Histopathologic and molecular biology tests are important tools in the
investigation of erythroderma.
P7571
Immunohistochemical detection of BRAF mutation in melanoma
Michelle Vernali, University of North Carolina School of Medicine, Chapel Hill,
NC, United States; Dan Zedek, MD, Department of Dermatology, University of
North Carolina School of Medicine, Chapel Hill, NC, United States; David W.
Ollila, MD, Department of Surgical Oncology, University of North Carolina School
of Medicine, Chapel Hill, NC, United States; Nancy E. Thomas, MD, PhD,
Department of Dermatology, University of North Carolina School of Medicine,
Chapel Hill, NC, United States
BRAF mutational status is a major factor in the clinical management of patients with
metastatic melanoma. Ninety percent of mutations within this gene are accounted
for by a missense substitution at amino acid position 600 (V600E), substituting
valine for glutamic acid. This results in constitutive phosphorylation of downstream
targets. Vemurafenib, a targeted BRAF kinase inhibitor, has demonstrated significantly increased overall and progression-free survival as compared to dacarbazine in
a phase III clinical trial. BRAF mutation status, and therefore eligibility for BRAF
inhibitors, is currently determined by sequencing methods. Recently, a monoclonal
antibody (VE1) against the BRAF V600E mutant protein has been developed. In this
study, we assessed the validity of VE1 in the detection of mutant BRAF V600E protein
as compared to the UNC CLIA-certified method of DNA pyrosequencing. We
analyzed 96 primary and metastatic melanomas from 76 patients with known
mutational status. Primary melanomas were immunostained and results matched to
their associated metastases to determine if staining remained consistent between
the two lesions. The staining intensity of these specimens was assessed by a
dermatopathologist blinded to all clinical and genetic data and scored from 0 to 3 (0
¼ no staining, 1 ¼ weak background staining, 2 ¼ moderately positive staining, and
3 ¼ strongly positive staining). Scores of 0 and 1 were considered to be negative
staining while scores of 2 and 3 were considered to be positive staining. The VE1
antibody demonstrated a sensitivity of 81% and a specificity of 100% as compared to
pyrosequencing. In addition, there was 100% concordance between primary and
metastatic lesions. Other BRAF mutations, including V600K, V600Q, and V600R did
not positively with the VE1 immunostain. The results of this study demonstrate the
clinical utility of the VE1 immunostain in the management of melanoma patients.
Commercial support: None identified.
Commercial support: None identified.
P8324
P7622
A population-based study on the association between bullous pemphigoid
and neurologic disease
Katherine Brick, MD, Mayo Clinic, Rochester, MN, United States; Carilyn
Wieland, MD, Mayo Clinic, Rochester, MN, United States; Chad Weaver, MD,
Mayo Clinic, Rochester, MN, United States; Christine Lohse, MS, Mayo Clinic,
Rochester, MN, United States; Lawrence Gibson, MD, Mayo Clinic, Rochester,
MN, United States; Mark Pittelkow, MD, Mayo Clinic, Rochester, MN, United
States; Michael Camilleri, MD, Mayo Clinic, Rochester, Minnesota, United States
The association between bullous pemphigoid (BP) and multiple neurologic diseases
has been well-documented, but population-based studies from the United States are
lacking. BP antigen 1 has similar isoforms in neuronal and cutaneous tissues, which
is one possible link to explain this association. However, the etiology of this
relationship is not well understood. A population-based study was performed to
examine this phenomenon. The Rochester Epidemiology Project was used to
identify 87 patients who were residents of Olmsted County, Minnesota at their first
lifetime diagnosis of BP between January 1, 1950 and December 31, 2009. An
additional 3 age- and sex-matched subjects who were also residents of Olmsted
County were used as controls for each BP case, and all charts were reviewed for the
presence of neurologic disorders (ie, dementia, Alzheimer disease, Parkinson
disease or other movement disorders, epilepsy, stroke, or multiple sclerosis) before
or after the diagnosis of BP. Any previous diagnosis of neurologic disease was
associated with a 6.85-fold increased odds of developing BP (odds ratio, 6.85; P \
.001). A history of dementia increased the odds of developing BP 6.75-fold (odds
ratio, 6.75; P ¼ .002), but in the 4 patients with Parkinson disease (n ¼ 3) or a
movement disorder (n ¼ 1), the increased odds were not statistically significant. For
the cohort arm of this study, those with a history of BP were significantly more likely
to develop Parkinson disease (hazard ratio, 8.56; P ¼ .014) as well as any type of
neurologic disease (hazard ratio, 2.02; P ¼.012) during follow-up. A limitation of our
study is the diagnosis of dementia could not be further subdivided because the
diagnosis was based on retrospective chart review. Our study confirms the
association of neurologic disorders and bullous pemphigoid, and specifically
provides population-based evidence for the association with dementia and
Parkinson disease. This supports need for additional investigation into the specific
mechanisms that may underlie these relationships.
Commercial support: None identified.
Melanoma associated with TNFa inhibitors: A research on adverse drug
reactions (RADAR) report
Beatrice Nardone, MD, PhD, Department of Dermatology, Northwestern
University, Chicago, IL, United States; Dennis P. West, PhD, Department of
Dermatology, Northwestern University, Chicago, IL, United States; Dennis W.
Raisch, PhD, College of Pharmacy, University of New Mexico, Albuquerque, NM,
United States; Gil Abramovici, MD, Department of Dermatology, Northwestern
University, Chicago, IL, United States; Jeave Reserva, MD, Department of
Dermatology, Northwestern University, Chicago, IL, United States; Josh A.
Hammel, MD, Department of Dermatology, Northwestern University, Chicago,
IL, United States
Introduction: Tumor necrosis factor-a inhibitors (TNFa Is), are widely used for
treatment of several dermatologic, rheumatologic, and gastrointestinal inflammatory disorders. Despite their therapeutic benefit, there is evidence linking these
agents with the occurrence of malignancies. For 4 out of 5 TNFa Is, the FDA label
states that ‘‘melanoma has been reported in patients treated with these agents.’’
Methods: We searched the FDA Adverse Event Reporting System (FAERS) database
for terms related to melanoma (M) combined with TNFa Is and we calculated
empirical Bayes geometric means (EBGM) for detection of safety signals. We also
searched a large urban academic electronic medical record (EMR) database ( [2.2
million individual records), for which we calculated the relative risk (RR) of
melanoma in subjects exposed to TNFa Is versus nonexposed subjects.
Results: Since the year of the drug approval date through December 2012, 1041
reports of melanoma-associated with a TNFa I were identified in the FAERS database.
A safety signal was detected for infliximab (I), n ¼ 434 (EBGM, 7.90; 95% CI, 7.138.6); golimumab (G), n ¼ 10 (EBGM, 5.34; 95% CI 2.41-9.88); etanercept (E), n ¼ 347
(EBGM, 2.49; 95% CI, 2.24-2.76); and adalimumab (A), n ¼ 237 (EBGM, 2.49; 95% CI,
2.19-2.83). Certolizumab pegol (CP), n ¼ 13 had no detectable safety signal. For the
EMR cohort, 6,045 were exposed to TNFa Is, and 35 cases of M were detected (I, n ¼
3; G, n ¼ 1; E, n ¼ 17; A, n ¼ 14; CP, n ¼ 0). Significant RR was detected for A (RR, 1.8;
95% CI, 1.06-3.0; P ¼.02) and E (RR, 2.35; 95% CI, 1.46-3.77; P ¼.0004). For TNFa Is
as a class of drugs, a safety signal was detectable in FAERS database (EBGM, 3.30; 95%
CI, 3.10-3.52) and RR was significant in EMR database (RR, 1.75; 95% CI, 1.25-2.43;
P \.0009).
Conclusion: We identified a significant association for exposure to TNFa Is and M,
for all drugs except CP in the FAERS dataset and for A and E in the academic dataset.
Interestingly, the current FDA labeling for certolizumab pegol does not include
melanoma as an adverse effect. Our findings add to existing evidence linking these
agents with the occurrence of melanoma. Additional investigations are required to
further explore this association and the risk of melanoma with TNFa Is therapy.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB1
P8398
P7657
Cardiovascular event risk assessment in psoriasis patients treated with
tumor necrosis factor-alfa inhibitors versus methotrexate
Jashin J. Wu, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA,
United States; Annie Gu
erin, Analysis Group, Inc, Boston, MA, United States;
Katherine Dea, Analysis Group, Inc, Boston, MA, United States; Ke Wang, AbbVie
Inc, North Chicago, IL, United States; Murali Sundaram, AbbVie Inc, North
Chicago, IL, United States; Parvez Mulani, AbbVie Inc, North Chicago, IL, United
States
Objective: Psoriasis (Ps) has been associated with increased risk of cardiovascular
(CV) disease. A prior study in Ps patients (pts) demonstrated a significant reduction
in myocardial infarction (MI) risk and incidence rate among TNF inhibitor (TNFi)
users versus those using topical agents. This study compared risk of major CV events
in Ps pts receiving MTX or TNFi and assessed impact of duration of treatment with
TNFi’s on long-term risk of major CV events.
Number needed to treat and cost per responder for biologic therapies for
the treatment of moderate to severe psoriasis
Richard G. Langley, Dalhousie University, Halifax, Canada; James Signorovitch,
Analysis Group, Inc, Boston, MA, United States; Ke Wang, Global Health Economics
and Outcomes Research, AbbVie, North Chicago, IL, United States; Keith A. Betts,
Analysis Group, Inc, Boston, MA, United States; Murali Sundaram, Global Health
Economics and Outcomes Research, AbbVie, North Chicago, IL, United States; Parvez
Mulani, Global Health Economics and Outcomes Research, AbbVie, North Chicago,
IL, United States; Sherry Yan, Analysis Group, Inc, Boston, MA, United States
Methods: Using a large US claims database (Q1 2000eQ3 2011), adult Ps pts with ¼
2 TNFi or MTX prescription fills were identified and classified as TNFi or MTX users,
respectively. Index date was TNFi initiation date for TNFi users and was randomly
selected among all MTX dispensing dates for MTX users. Pts initiating both a TNFi
and MTX on the same day were excluded. All pts were continuously enrolled in their
health plan for ¼ 6 months before (baseline period) and after index date. Pts were
observed from index date until first major CV event (MI, stroke or transient ischemic
attack [TIA], unstable angina [UA], and congestive heart failure) that led to
hospitalization, end of continuous health plan enrollment, or 6 months after
treatment discontinuation, whichever occurred first. KaplaneMeier rates were
estimated at 12 months. Risk of major CV events was compared between cohorts
using Cox proportional hazards (Cox) models while adjusting for potential baseline
confounding factors. Time-varying Cox models were used to model the effect of the
duration of TNFi treatment (cumulative exposure to TNFi over time) on the risk of
major CV events.
Results: A total of 9,148 TNFi users and 8,581 MTX users met the inclusion criteria.
At 12 months, KaplaneMeier estimates of any major CV events were 1.87% and
5.52% for TNFi and MTX users, respectively (P \.01). After adjusting for potential
confounding factors, the TNFi cohort had significantly lower risks than the MTX
cohort in any major CV event (hazard ratio [HR]: 0.58), and individually, stroke or
TIA [HR ¼ 0.56], UA [HR ¼ 0.57], and MI [HR ¼ 0.48]. In addition, each incremental
6 months of cumulative exposure to TNFi was associated with a 12% reduction of
the risk of major CV event (HR, 0.88; P ¼.01) over a median observation period of 23
months.
Conclusions: Ps pts initiated on TNFi had a significantly lower risk of major CV
events vs. pts on MTX. Each incremental 6 months of cumulative exposure to TNFi
significantly reduced the risk of major CV event.
Design, study conduct, and financial support for the study were provided by
AbbVie. AbbVie participated in the interpretation of data, review, and approval of
the abstract. All authors contributed to the development of the publication and
maintained control over the final content.
Objectives: The clinical benefits of biologic therapies have been well established,
but wide variations exist in the response of patients with psoriasis to these
therapies. The objective of this study is to determine the number needed to treat to
achieve a 75% reduction in the Psoriasis Area and Severity Index (PASI-75) with
different biologic agents and evaluate the incremental cost per PASI-75 responder for
biologic treatments during the first 10 to 16 weeks of treatment.
Methods: A systematic literature review was conducted to identify randomized
controlled trials of biological treatments in patients who had moderate to severe
psoriasis. The relative probabilities of achieving PASI-75 response with each biologic
treatment were estimated using a Bayesian network metaanalysis. The number
needed to treat was estimated for each biologic treatment as the reciprocal of the
difference in estimated PASI-75 response rates between the biologic treatment and
supportive care (no systemic therapy). Costs were assessed in terms of 2011 British
pounds (£), and included drug acquisition, administration, laboratory tests, and
outpatient visits. Cost-effectiveness from the UK National Health Service (NHS)
perspective was assessed as the incremental cost per PASI-75 response for biologic
treatments compared with supportive care.
Results: A total of 15 trials meeting all inclusion criteria were identified through the
systematic literature review. Based on the results of the Bayesian network metaanalysis, the number needed to treat to achieve PASI-75 response was 1.28 [95%
credible interval: 1.20-1.37] for infliximab 5 mg/kg, 1.49 [1.39-1.61] for ustekinumab
using weight based dosing, 1.58 for adalimumab 40 mg EOW [1.44-1.81], 2.10 [1.862.38] for etanercept 50 mg BIW, and 3.05 [2.50-3.78] for etanercept 25 mg BIW. The
incremental cost per PASI-75 responder was £6,130 [5,572-7,020] for adalimumab,
£7,221 [6,740-7,817] for ustekinumab, £7,570 [7,091-8,101] for infliximab, £8,019
[6,573-9,930] for etanercept 25 mg, and £10,188 [9,007-11,544] for etanercept 50 mg.
Conclusions: This study provides an overview of the clinical and economic evidence for
biologic treatments for moderate to severe psoriasis. Infliximab was found to require
the lowest number needed to treat to achieve PASI-75 response, and adalimumab was
found to be the most cost-effective in terms of incremental cost per PASI-75 responder.
Design, study conduct, and financial support for the study were provided by
AbbVie. AbbVie participated in the interpretation of data, review, and approval of
the abstract. All authors contributed to the development of the publication and
maintained control over the final content.
P8033
P7885
Interleukin 33 is differentially expressed in psoriasis-like drug reactions
to TNF antagonists
Antonios Kolios, MD, University Hospital Zurich, Zurich, Switzerland; French
Lars, MD, University Hospital Zurich, Zurich, Switzerland; Navarini Alexander,
MD, PhD, Universtiy Hospital Zurich, Zurich, Switzerland
Since their introduction, TNF-a antagonists play a major role in the treatment of
autoimmune disorders like psoriasis, rheumatoid arthritis, ankylosing spondylitis,
Crohn’s disease and others. Probably because of to their immunologic nature, these
drugs sometimes produce puzzling cutaneous side effects that are the subject of this
investigation. For instance, although TNF-a antagonists are used to treat psoriasis,
they can produce paradoxical skin inflammation in a small fraction of patients that
can clinically resemble psoriasis, dermatitis and other conditions. Of 21 patients (13
female, av. 48 years), 47% had a reaction either to infliximab and adalimumab or both
(1 patient) and 6% had a reaction to etanercept. Clinical features as well
immunohistochemistry for TNF-a, INF-a, IL-1-beta, IL-22, IL-6, IL-17, CD123, IL33,
MXA, IL-8 and IL-36a were performed. In each patient, 2 histologic samples were
taken and were evaluated by a grading system from + to ++++ (weak, medium,
strong and highly active signal) as well as +/- (indifferent) and e (negative). Control
stainings were performed at plaque psoriasis samples. IL-33 was expressed in 86.1%
of psoriasis-like or pustular reactions (PPR) but only in 55.6% of dermatitis-like
reactions (DLR) (P ¼.009; Fisher exact test). IL-1-beta was expressed in both PPR and
in DLR in 63.9% (not significant [n.s.]). IL-22 was expressed in 100% of PPR and in
97.2% of DLR (n.s.). IL-6 was expressed in 58.3% of PPR and in 61.1% of DLR (n.s.).
IL-17 was expressed in 88.9% of PPR and in 94.4% of DLR (n.s.). CD123 was
expressed in 44.4% of PPR and in 36.1% of DLR (n.s.). TNF-a was expressed in 88.9%
of PPR and in 86.1% of DLR (n.s.). IFN-a was expressed in 91.7% of PPR and in 97.2%
of DLR (n.s.). MXA was expressed in 83.3% of PPR and in 80.6% of DLR (n.s.). IL-8
was expressed in 77.8% of PPR and in 83.3% of DLR (n.s.). IL-36a was expressed in
66.7% of PPR and in 52.8% of DLR (n.s.). The alarmin IL-33 is a member of the IL-1
family and is overexpressed in plaque psoriasis. In histologic samples of reactions to
TNF- a antagonists, we detected a differential expression of IL-33 in PPR but less so in
DLR. Further investigations will define the role of this cytokine in these rare
cutaneous side effects of anti-TNF-a inhibitor therapy.
Commercial support: None identified.
AB2
Secukinumab efficacy in subjects with moderate-to-severe plaque psoriasis
and concomitant psoriatic arthritis: A subanalysis of the ERASURE study
Andrew Blauvelt, Oregon Health & Science University, Portland, OR, United States;
Alice Gottlieb, MD, PhD, Tufts University Medical Center, Boston, MA, United
States; Bardur Sigurgeirsson, MD, PhD, University of Iceland, K
opavogur, Iceland;
Charis Papavassilis, Novartis Pharma AG, Basel, Switzerland; Ruvie Martin, PhD,
Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
Background: Secukinumab (AIN457), a fully human antieinterleukin-17A monoclonal antibody, was evaluated to assess the efficacy of 2 doses (150 and 300mg
subcutaneous [s.c.]) at wk 12 and safety, tolerability, and long-term efficacy (up to 52
wks) compared with placebo in subjects with moderate-to-severe plaque psoriasis.
Because psoriatic arthritis (PsA) is a common comorbidity in persons with psoriasis
and may confer a substantial disability burden, a subanalysis was conducted in
subjects with moderate-to-severe plaque psoriasis and PsA confirmed by CASPAR
diagnostic criteria or Psoriasis Arthritis History eCRF at screening.
Methods: ERASURE (NCT01365455) was a randomized, double-blind, placebocontrolled, multicenter, phase 3 study conducted between June 2011 and April
2013. Study design and methodology for the primary study and current subanalysis
have been reported elsewhere. In this subanalysis, secukinumab’s effect in subjects
with a history of PsA was evaluated with the Psoriasis Area and Severity Index (PASI)
and the Health Assessment QuestionnaireeDisability Index (HAQ-DI).
Results: In the overall study population at wk 12, PASI 75 responses were achieved by
72% of secukinumab 150 mg and 82% of secukinumab 300 mg subjects vs 5% in the
placebo group (both P\.001 when unadjusted or adjusted for multiple testing). In the
subpopulation with concomitant PsA (n ¼ 171), baseline PASI and HAQ-DI scores were
balanced across treatments. PASI 75 responses at wk 12 were 70% in the 150 mg group
and 68% in the 300 mg group (4%, placebo); PASI 90 responses were 44% and 53% in the
150 and 300 mg groups, respectively (0%, placebo). PASI 75 responses (61%, 150 mg;
68%, 300 mg) and PASI 90 responses (37%, 150 mg; 56%, 300 mg) were maintained up
to 1 year. Physical function as measured by HAQ-DI change from baseline was
significantly greater at wks 4 and 12 with 300 mg vs placebo (P \.05). HAQeDI
responses were more pronounced in patients with more disability. In patients with
baseline HAQ-DI ¼ 0.5, reduction in HAQ-DI score was statistically significantly greater
for 150 mg at wk 12 and for 300 mg at wks 4 and 12 vs placebo and responses continued
up to wk 52. Secukinumab was well tolerated with no unexpected safety findings.
Conclusions: In subjects with psoriasis and concomitant PsA, secukinumab was
associated with superior improvement in skin symptoms and physical functioning
versus placebo. These data strongly support continued evaluation of secukinumab
in PsA.
Supported by Novartis Pharma AG.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
PEARLS FROM THE POSTERS: TOP CASE STUDIES
AND REPORTS
P7869
RothmundeThomson syndrome. A 13-year follow-up
Guillermo Antonio Guerrero-Gonzalez, MD, Hospital Universitario ‘‘Dr. Jose E.
Gonzalez’’ UANL, Monterrey, Mexico; Alejandra Lorena Tamez-Pe~
na, MD, Hospital
Universitario ‘‘Dr. Jose E. Gonzalez’’ UANL, Monterrey, Mexico; Jorge OcampoCandiani, MD, Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’ UANL, Monterrey,
Mexico; Minerva G
omez-Flores, MD, Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’
UANL, Monterrey, Mexico; Sylvia Aide Martınez-Cabriales, MD, Hospital
Universitario ‘‘Dr. Jos
e E. Gonzalez’’ UANL, Monterrey, Mexico
RothmundeThomson syndrome (RTS) is a rare autosomal recessive disorder. To
date, around 300 cases have been reported and 2 clinical forms have been described:
Type I, characterized by poikiloderma, ectodermal dysplasia, and juvenile cataracts
with unknown etiology; and Type II with poikiloderma, congenital bone defects, an
increased frequency of malignancy (specially osteosarcoma) and mutations in the
RECQL4 helicase gene at chromosome locus 8q24.3 as the underlying cause. It has
yet to be clarified whether these 2 forms represent 2 different syndromes with
common features or clinical entities involving different genes acting on the same
pathway. We present the case of a 13-month-old female with a facial rash with
blisters on her cheeks and limbs starting at the age of 3 months along with congenital
hypoplastic thumbs, frontal bossing and fine hair with thinning of the brows and
eyelashes. A skin biopsy specimen revealed epidermal atrophy and dermoepidermoid edema and RTS was diagnosed. The patient lost follow-up and returned 12
years later with palmoplantar hyperkeratotic lesions, a short stature, disseminated
poikiloderma, cafe au lait spots on the trunk, and sparse scalp hair with absence of
eyelashes and brows. Radiographic analysis showed radial ray defect, absence of the
thumb and three wrist carpal bones, and reduction in bone density. Neurologic
development was normal and upon ophthalmologic examinations no cataracts or
other alterations were found. Gene sequencing revealed mutations in the RECQL4
helicase gene. RTS is a rare disease, and in this patient we observed the evolution of
her skin lesions and other clinical features, which were important for the
classification of type II RTS. Even though dermatologic screening and radiographic
assessment were performed with no evidence of neoplastic disease, the continual
screening for malignancy is warranted due the high prevalence for osteosarcoma
(30%) and skin cancer (5%) in these patients. The follow-up for the next years will
allow us to improve our understanding of the disease.
P8428
Folliculotropic mycosis fungoides: Eight cases report
Pablo Hernandez Bel, MD, Consorcio Hospital Provincial Castell
on, Castell
on,
Spain; Amparo Gonzalez, MD, Consorcio Hospital General Valencia, Valencia,
Spain; Amparo Perez Ferriols, MD, Consorcio Hospital General Valencia,
Valencia, Spain; Arantxa Torrijos Aguilar, MD, Consorcio Hospital Provincial
Castell
on, Castell
on, Spain; Vıctor Alegre de Miquel, MD, Consorcio Hospital
General Valencia, Valencia, Spain
Background: Folliculotropic mycosis fungoides (MF) is a rare variant of cutaneous
T-cell lymphoma in which the neoplastic T lymphocytes display tropism for the
follicular epithelium.
Objectives: To better categorize this rare form of cutaneous T-cell lymphoma we
evaluated the clinical, pathologic, and immunophenotypic findings, and the
response to therapy and course of the disease.
Methods: Folliculotropic MF cases were selected from the registry of the Thematic
Network of Cutaneous Lymphoma of Valencia (Spain) from 2006 to 2013.
Results: Eight patients (5 male, 3 female) with a mean age of 56 years were included.
Mean follow-up time was 43 months. The most common sites of involvement were
the head and neck (80%), upper extremities, and thorax. Infiltrated plaques (55%),
acneiform lesions (comedo-like and epidermal cysts; 45%), and follicular keratosis/
pilariselike lesions (45%) were the more prominent features. Histopathologic
findings included selective infiltration of the follicular epithelium by atypical
lymphocytes in all cases. Mucinous degeneration of the follicular epithelium
occurred in 60% of cases. Psoralen plus ultraviolet A therapy was the treatment of
choice in the majority of patients, but these patients did not respond as well as
patients with classic MF. Radiotherapy (local or total skin electron beam) was found
to be the most effective treatment. A good response to bexarotene was seen in some
patients.
Limitation: This was a case series descriptive study.
Conclusions: Folliculotropic MF is a rare but well-defined clinicopathologic variant
of MF. Although refractory to standard therapies used in classic MF, most of our
patients showed only slow disease progression.
Commercial support: None identified.
Commercial support: None identified.
P8657
Demodex inflammatory eruption due to EGFR inhibitor therapy
Amanda Hassler, University of Texas Medical School at Houston, Houston, TX,
United States; Susan Chon, MD, MD Anderson, Houston, TX, United States
Background: Targeted therapies have offered great benefits to the treatment of
cancer by improving survival while producing fewer side effects such as hematopoietic and GI effects compared to traditional chemotherapies. However, dermatologic toxicities have been a significant and frequent side effect of targeted therapies.
One class of targeted therapy, EGFR inhibitors, has been used as anti-tumor agents in
colorectal cancer, squamous cell carcinoma of the head and neck, and non-small cell
lung cancer. The most common dermatologic adverse effect is a now welldocumented papulopustular eruption that occurs in up to 90% of patients receiving
EGFR inhibitors. Generally this papulopustular eruption is treated with a range of
therapy that can include topical steroids and antibiotics to oral steroids and
antibiotics for more severe cases.
Observations: We report a series of 2 patients undergoing treatment with EGFR
inhibitors, cetuximab and panitumumab, who presented with papulopustular
eruption within 1 week of beginning therapy. The eruption consisted of confluent
inflammatory pustules throughout the face and neck with a background of
erythema. Their eruptions were initially treated as a drug reaction secondary to
EGFR inhibitor therapy with oral tetracyclines along with topical steroids and
clindamycin. After these initial treatments failed, scrapings of the pustules with
mineral prep showed Demodex mites. Treatment with ivermectin and permethrin
resulted in almost immediate and complete resolution.
Discussion: Demodex folliculitis has not been previously reported as an adverse
effect in EGFR inhibitor therapy and there have been no reported cases of successful
treatment of the papulopustular eruption with antiparisitics. It has been shown that
patients with papulopustular eruptions related to EGFR inhibitor therapy have an
increased density of Demodex folliculorum. It is hypothesized that EGFR inhibitor
therapy reduces microbial defense allowing for mite proliferation while inducing
chemokines that potentiate an inflammatory reaction. The fulminant nature and
appearance of the eruption can be psychologically devastating to the patients and
can potentially result in a disruption in their treatment. Thus, it is important to
consider doing a scraping of pustules when patients do not respond to traditional
therapy. This is especially essential when there is an increased number of pustules or
the distribution is concentrated to the head and neck.
Commercial support: None identified.
P8583
Intravascular large B-cell lymphoma: Report of a case and review of the
literature
Penvadee Pattanaprichakul, MD, Department of Pathology, Section of
Dermatopathology, University of Texas MD Anderson Cancer Center, Houston,
TX, United States; Jonathan L. Curry, MD, Department of Pathology, Section of
Dermatopathology, University of Texas MD Anderson Cancer Center, Houston,
TX, United States; Michael T. Tetzlaff, MD, PhD, Department of Pathology,
Section of Dermatopathology, University of Texas MD Anderson Cancer Center,
Houston, TX, United States; Samuel A. Henderson, MD, Department of Pathology,
Section of Dermatopathology, University of Texas MD Anderson Cancer Center,
Houston, TX, United States; Victor G. Prieto, MD, PhD, Department of Pathology,
Section of Dermatopathology, University of Texas MD Anderson Cancer Center,
Houston, TX, United States
Intravascular large B-cell lymphoma (IVLBCL) is a rare disease that consists of a
proliferation of malignant B cells confined within small blood vessels with a
predilection for the skin and central nervous system. It is classified as an aggressive
variant of extranodal diffuse large B-cell lymphoma (DLBCL) according to the 2008
WHO lymphoma classification. Performing a skin biopsy on suspicious cutaneous
lesions may facilitate diagnosis and early management. We report a case of IVLBCL in
a 70 year-old man who had been experiencing progressive weight loss, abdominal
pain and a diffuse, indurated erythematous eruption over a 3-month period. Biopsy
from an abdominal lesion revealed a proliferation of cytologically malignant
mononuclear cells filling and expanding vascular spaces of the deep dermis and
subcutaneous tissue. Immunohistochemical studies demonstrated the intravascular
tumor cells to be strongly and diffusely positive for CD20, Bcl-2, and Mum-1 and
strongly, but patchy for Bcl-6. The tumor cells were negative for CD2, CD3, CD5,
cyclin D1 and CD10. Many hypotheses have been postulated to explain the
mechanism underlying the predilection of the tumor cells for the vascular lumina.
Immunohistochemical studies have demonstrated that IVLBCL cells lack certain cell
adhesion molecules (CD29, CD54 (ICAM1), integrin B1, and CD11a) and certain
matrix metalloproteinases (MMP) such as MMP-2 and MMP-9, which are important
for vascular extravasation and parenchymal invasion by the tumor cells. We use our
index case to explore and review these various mechanisms, which explain the
unique and interesting histopathologic distribution of the tumor cells in IVLBCL.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB3
P8313
P8346
Drug-induced skin pigmentation: 3 cases to report
Nerea Barrado-Solıs, Hospital Arnau de Vilanova, Valencia, Spain; Beatriz RodrigoNicolas, Hospital Arnau de Vilanova, Valencia, Spain; Cesar Lloret-Ruiz, Hospital
Arnau de Vilanova, Valencia, Spain; Enrique Gimeno-Carpio, Hospital Arnau de
Vilanova, Valencia, Spain; Esther Quecedo-Estebanez, Hospital Arnau de
Vilanova, Valencia, Spain; Paula Moles-Poveda, Hospital Arnau de Vilanova,
Valencia, Spain
Psoriasiform eruption in the setting of West Nile virus
Robyn Marszalek, MD, Boston Medical Center Department of Dermatology,
Boston, MA, United States; Amy Y-Y. Chen, MD, Boston Medical Center
Department of Dermatology, Boston, MA, United States; Jessica Gjede, MD,
Boston Medical Center Department of Dermatology, Boston, MA, United States
Introduction: Skin pigmentation is a frequent drug side effect, which accounts for
up to 20% of acquired pigmentation, especially in polymedicated elderly patients,
thus it should be included in the differential diagnosis of pigmented macules. We
report 3 cases of drug-induced pigmentation to highlight the importance of this
diagnosis.
Clinical cases: CASE 1: An 85-year-old woman presented with bilateral blue-grey
macules in the pretibial area for several months. A blue macule was observed in the
hard palate also. The patient had been treated for years with cloroquine due to
rheumatoid arthritis. The skin biopsy was compatible with pigmentation by
antimalarians. CASE 2: A 78-year-old man presented with blue-black pigmentation
in temples and back of the neck. The patient acknowledged to have received
minocycline for a long time because of a scalp folliculitis. The skin biopsy was
compatible with minocycline pigmentation. CASE 3: A 59-year-old man was referred
for brown annular pigmentation in penis and incipient pigmented lesions in finger
pads after treatment with capecitabine for an advanced esophagus adenocarcinoma.
Discussion: Pigmentary disorders are an adverse effect of diverse drugs, mainly
antiinflammatories, tetracyclines, heavy metals, antimalarials, amiodarone, and
cytotoxic agents. Chloroquine is a frequently used antimalarial, but its use has
multiple cutaneous side effects, like blue-grey pigmentation on face, nails, hair,
extremities and hard palate. Among tetracyclines, pigmentary changes are more
frequently produced by minocycline. These may occur in 3 clinical patterns: blue
discoloration in previously inflamed areas or acne scars, blue pigmentation in lower
extremities, and hyperpigmentation in sun-exposed areas. Capecitabine is a novel
oncologic drug available for treatment of metastatic cancer, mainly breast and
colorectal carcinoma. It is responsible for the hand-foot syndrome or erythrodysesthesia and skin pigmentation that can be generalized or localized on palms and soles.
The pathogenic mechanism depends on the causing agent. Pigmentation appears
insidiously over months or years following the initiation of the drug and tends to
worsen with sun exposure. Usually, pigmentation regresses after drug withdrawal.
We aim to highlight the importance of considering this diagnosis, especially in
polymedicated elderly patients who are more often attended in daily practice
nowadays.
We report a 56-year-old man who was admitted to the intensive care unit for fevers,
weakness, respiratory failure, and altered mental status. He subsequently developed
the sudden onset of ill-defined pseudovesicular erythematous papules on the palms
and well defined pink scaly psoriasiform papules and plaques on the feet and thighs.
A viral exanthem was suspected clinically, and West Nile virus (WNV) PCR from the
cerebrospinal fluid was subsequently positive. Punch biopsies from the left medial
ankle and left palm revealed confluent parakeratosis, scale crust with neutrophils,
psoriasiform epidermal hyperplasia with spongiosis, patchy hypogranulosis, mild
superficial perivascular lymphocytic infiltrate, and papillary dermal telangiectasia.
This was indicative of a psoriasiform dermatitis. The patient noted a family history of
psoriasis but no clear personal history. The eruption responded to high potency
topical steroids. After emerging in North America in 1999, the Flavivirus identified as
the WNV is now a well-known cause of infectious meningitis and encephalitis.
Transmission of the virus occurs during active feeding of the Cluex, Ochlerotatus, or
Aedes mosquito. The clinical severity of WNV is varied and can range from
asymptomatic infection to meningoencephalitis, coma, and death. Common
manifestations include fever, malaise, anorexia, photophobia, ocular pain, myalgias,
arthralgias, lymphadenopathy, weakness, and skin eruption. While ‘‘new rash’’ has
been independently associated with recent WNV infection and as many as 20% to
50% of patients present with rash, the cutaneous manifestations associated with
WNV have not been well delineated in the literature. Transient, asymptomatic,
punctate morbilliform macules and papules resembling folliculitis have been
described, largely contained on the extremities and trunk. Plantar petechiae and
facial involvement have also been observed. Histopathologic evidence is sparse,
with only 1 case demonstrating a sparse superficial perivascular lymphocytic
infiltrate similar to other viral exanthems. To the best of our knowledge, the
association of WNV stimulating a psoriasiform eruption, akin to other infectious
psoriasis triggers such as streptococcus, has not been previously described in the
literature. In the appropriate clinical setting, physicians should consider WNV in the
differential diagnosis of patients presenting with fever, neurologic abnormalities,
and new or flaring psoriasiform eruption.
Commercial support: None identified.
Commercial support: None identified.
ACNE
P7596
Vismodegib-induced amenorrhea: Mechanism of FSH blockade and implication for tumor angiogenesis.
John Strasswimmer, MD, PhD, Delray Mohs Surgery, Delray Beach, FL, United
States
Purpose: Vismodegib is an oral medication for advanced BCC (aBCC) with a
reported side-effect of amenorrhea in some women. We discovered the novel unique
mechanism of action.
Design: A patient with aBCC presented in June 2011 with a nonresectable aBCC
overlying the carotid sheath. She commenced vismodegib at 150 mg/day in August
2011. In September 2011 until the present she has been amenorrheic.
Results: The reproductive endocrine examination and testing results were unique
and novel. Her elevated FSH and low estrogen level were indicative of a markedly
diminished ovarian function as seen in menopause. However, the persistence of
preantral follicles and the antimullerian hormone value indicate preservation of
normal ovarian potential and potential reversal of effect following cessation of
therapy. This implies that the hedgehog pathway may be involved in FSH-dependent
physiologic signaling action at the ovarian follicle level. As vismodegib interferes
with signal transduction, it is likely that vismodegib acts by blocking FSH-receptor
dependent signal transduction. Dermatologists are the primary prescribers for
vismodegib and have should ensure that women on vismodegib are appropriately
screened and monitored for menopausal events. In addition, this new class of agents
might form the basis for other Hh interventions in gynecologic and metabolic
disease, as elevated FSH in menopause may have direct causal relationship with
osteoporosis. Finally, FSH-receptor is heavily overexpressed in a variety of noneskin
cancer malignancies and blockade of the FSH-receptor function with vismodegib or
related compounds may have a role in treating tumor neoangiogenesis. We report
the first evidence that hedgehog pathway inhibition may affect normal adult
reproductive endocrine physiology and implications beyond treatment of BCC.
Commercial support: None identified.
AB4
P8350
A meta-analysis to evaluate the efficacy and safety of adapalene-benzoyl
peroxide topical gel in black subjects with mild or moderate acne
Andrew F. Alexis, MD, MPH, Skin of Color Center, St. Luke’s-Roosevelt Hospital,
New York, NY, United States; Nabil Kerrouche, MS, Galderma R&D, SNC, Biot,
France; Valerie D. Callender, MD, Callender Dermatology & Cosmetic Center,
Glenn Dale, MD, United States
Adapalene, a synthetic retinoid analogue, and benzoyl peroxide, an effective
antimicrobial agent, are currently available at concentrations of 0.1% and 2.5%,
respectively, as a fixed combination gel (A-BPO) for the treatment of acne. Results
from 3 multicenter, randomized, double-blind, vehicle-controlled, clinical trials of
adapalene benzoyl peroxide (A BPO) gel were analyzed in a prospective subgroup
meta analysis. Subjects were assessed at weeks 1, 2, 4, 8, and 12 for efficacy and
safety. The analysis included 238 self-identified black subjects in the A-BPO and
vehicle treatment groups who were treated for 12 weeks. This subgroup was
comprised primarily of women with Fitzpatrick skin types V and VI and a mean age
of 21.3 years. After 12 weeks of treatment, significantly more subjects achieved IGA
success with A-BPO (n ¼ 121; 31.4%) than with vehicle (n ¼ 117; 14.5%; P \.001).
Significant reductions in median total lesions were observed with A BPO compared
to vehicle at all postbaseline visits (P \ .01). Most subjects did not experience
cutaneous irritation. Of those who did, their worst tolerability scores were mostly
none or mild for all treatment groups. Most reported adverse events (AEs) were mild
in severity. Two subjects reported serious AEs that were unlikely related to the study
treatment: 1 AE of worsening depression in the adapalene BPO group and 1 AE of
miscarriage in the vehicle group. Four subjects discontinued treatment due to AEs.
In conclusion, treatment with A-BPO in black subjects with mild to moderate acne
was effective and well tolerated.
Supported by Galderma Research & Development, SNC. Poster/editorial support
provided by Galderma Laboratories, L.P.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8408
P8726
A psychological intervention for people with acne excoriee: A case series
Reena Shah, Barts Health NHS Trust, Leytonstone, London, United Kingdom; Alia
Ahmed, Barts Health NHS Trust, London, United Kingdom; Anthony Bewley,
Barts Health NHS Trust, Leytonstone, London, United Kingdom
Introduction: Acne excoriee (AE) is considered to be self-inflicted dermatoses where
patients openly report having the compulsive urge to manipulate the acne and
picking imagined papules causing the acne to spread. The condition can be chronic,
recurring, and often resistant to standard dermatologic and psychiatric treatment. In
clinical practice patients may exhibit 2 different entities: habitual and emotional
picking. Habit reversal therapy (HRT) reduces eczema patients’ habitual scratching,
and can be helpful for patients with AE with habitual picking. It well known that
stress can exacerbate skin conditions. Relaxation can reduce patient’s levels of
stress, which has been postulated as perpetuating emotional picking.
Methods: A retrospective case notes review of 3 patients presenting to a
psychodermatology service, specifically to clinical psychology. Sessions included
patient assessment. A simple cost effective integrated psychological intervention
was facilitated and standardised measures were administered pre- and
postintervention.
Acne fulminans triggered by isotretinoin therapy
G€
oksun Karaman, MD, Adnan Menderes University, Aydin, Turkey; Ekin Savk,
MD, Adnan Menderes University, Aydin, Turkey; Meltem Uslu, MD, Adnan
Menderes University, Aydin, Turkey; Neslihan Sendur, MD, Adnan Menderes
University, Aydin, Turkey
Results: Three white females (aged between 18-38 years; mean age, 30 years) were
referred for psychological assessment and treatment after medical treatment was
unsuccessful (including phototherapy, topical treatment and psychiatric medication). Patients’ histories revealed that they all had acne as a teenager. Due to feelings
of imperfection and beliefs regarding skin hygiene and body image, picking served
as a function to enhance appearance; however, it eventually became a coping
strategy for emotional negative and unhelpful beliefs. After a period of time, some
picking was then deemed habitual; hence at assessment emotional and habitual
picking were present. One-to-one HRT integrated with relaxation was conducted for
8 sessions. Pre and post scores on standardised measures indicated a reduction in
picking, decrease in appearance concern and anxiety and depression scores and
increased quality of life.
Conclusion: Treating patients with acne excoriee can be challenging due to the
probable underlying psychological factors perpetuating the picking. It is important
to assess for both habitual and emotional picking. Hence a referral to a psychologist
and using a simple integrated psychological intervention can reduce picking,
optimizing patient holistic treatment. To our knowledge, this is the first reported
case series of a psychological intervention treating patients rewardingly with acne
excoriee.
A 17-year-old male, with nodulocystic acne of 2 years’ duration, did not improve
with different kinds of systemic and topical acne therapies. Therefore he was started
on oral isotretinoin (0.8 mg/kg/day) therapy. In the second month of isotretinoin
treatment, he was admitted to our clinic with fever, chest pain, and muscle
tenderness. His dermatologic examination revealed highly inflammatory, haemorrhagic, tender, crusted nodules on the face and upper chest. Laboratory examinations of a blood sample revealed leukocytosis (20 3 109/L) and also erythrocyte
sedimentation rate (81 mm/hour; 0-20 range), C-reative protein (174 mg/L; 0-8
range), AST (76 U/L; 0-40 range), and ALT (75 U/L; 0-45 range) were all elevated.
Whole-body bone scintigraphy was normal. The symptoms could be under control
with 60 mg/kg/day prednisolone. Acne fulminans is an uncommon variant of acne
with sudden onset of ulcerated acne lesions and systemic symptoms in which
isotretinoin is a choice of treatment. We present our case to keep in mind that
paradoxically isotretinoin can trigger this acne variant.
Commercial support: None identified.
Commercial support: None identified.
P8481
Acne versus rosacea: Therapeutic response impacts topical dermatologic
product usage—An observational study
Pranathi Lingam, MD, Northwestern University Feinberg School of Medicine,
Department of Dermatology, Chicago, IL, United States; Alfred Rademaker, PhD,
Northwestern University Feinberg School of Medicine, Department of
Dermatology, Chicago, IL, United States; Bethanee J. Schlosser, MD, PhD,
Northwestern University Feinberg School of Medicine, Department of
Dermatology, Chicago, IL, United States; Dennis P. West, PhD, Northwestern
University Feinberg School of Medicine, Department of Dermatology, Chicago,
IL, United States; Elizabeth Damstetter, MD, Northwestern University Feinberg
School of Medicine, Department of Dermatology, Chicago, IL, United States
P8724
Acne and stress: A complex interrelationship
Deep Joshipura, MD, MBBS, P. D. U. Medical college, Rajkot, India; Suresh
Joshipura, MD, MBBS, Skin Center, Rajkot, India
Introduction: Acne vulgaris is a common skin disease with patients suffering from
psychological stress owing to esthetic distress on face.
Aim: To determine the level of stress in acne vulgaris and evaluate the effect of
treatment on stress.
Methods: 150 patients were evaluated. After consent and routine clinical history,
stress was evaluated using Hamilton Anxiety Rating (HAM-A) scale on first and all
subsequent follow ups. The scale consists of 14 items, each defined by series of
symptoms and measures both psychic and somatic anxiety. Each item is scored on a
scale of 0 (not present) to 4 (severe), with total score range 0 to 56. Global acne
rating scale was used for clinical grading on first and all subsequent visits.
Results: 72% patients had pretreatment HAM-A score between 18-24, while 78% had
score of 25-30. Mean value of HAM-A in pretreatment group was 24.05 and
posttreatment was 22.07. Mean difference was 2.43, indicating decrease in mean
following treatment. T test was applied for comparison. T value came out to be t ¼
28.402, which is statistically significant. The mean score of Global Acne grading
system at first visit was 17.84 and at end of treatment was 12.24 indicating good
response.
Background: Medication nonadherence is a pervasive, multifactorial obstacle to
optimizing therapeutic response in chronic dermatologic conditions. Although
medication underuse is common, an observational study of 8 subjects with
moderate acne vulgaris (AV) enrolled in a 12-week, phase 2 clinical trial of a novel
topical investigational product (IP) revealed increased daily IP consumption in a
compensatory attempt to enhance therapeutic efficacy. We therefore investigated
the presence of similar trends in patient behavior in papulopustular rosacea (PPR) IP
use.
Methods: 13 subjects with moderate to severe PPR were recruited at a single site to
participate in a multicenter, 12-week phase 3 randomized, double-blind, vehiclecontrolled trial of a novel topical IP. Subjects were randomly assigned to active drug
or vehicle (2:1). IP was a cream formulation dispensed at week 0 in two 30 g tubes
with collection and resupply at week 4 and 8. All subjects were instructed to apply a
pea-sized amount of IP to each of 5 facial treatment areas once daily at bedtime.
Application technique was demonstrated by a single research team member at
baseline (week 0) and reinforced at weeks 2, 4, and 8. Total lesion counts and IP
weights to the nearest 0.1 g were performed at weeks 2, 4, 8, and 12.
Results: Blinded evaluable data from 13 subjects did not demonstrate a significant
correlation between overall IP consumption at week 12 or change in IP consumption (g/dose) over time and percent reduction in total lesion count at week 12 (r ¼
-0.312; P ¼ .30) despite a significant percent reduction in total lesion count (P ¼
.0001) at week 12.
Conclusion: In our study, patient had statistically significant improvement in levels
of stress following cure of their acne lesions. The cosmetically disturbing acne
lesions increased the level of anxiety in these patients. Acne has a major impact on
the psyche. Treating acne effectively often induces psychosocial improvement.
Discussion: Unlike the strong inverse correlation between clinical response and
overall IP consumption at week 12 observed in AV subjects, there was no statistically
significant correlation between these two variables in PPR subjects. Despite a high
burden of inflammatory lesions at baseline, PPR subjects experienced a significant
percent reduction in total lesion count at week 12; this improvement could explain
the lack of compensatory increase in IP usage as observed in AV subjects where a
similar reduction in lesion count was not noted. Thus, clinical response plays a
significant role in medication usage patterns, and compensatory medication overuse
to enhance diminished therapeutic efficacy has important clinical implications.
Commercial support: None identified.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB5
P7979
P8369
Are tetracycline-resistant Propionibacterium acnes increasing in our acne
community?
Mohammed Sayeedullah Shareef, Harrogate and District Hospital NHS
Foundation Trust, Harrogate, United Kingdom; Alison Layton, Harrogate and
District Hospital NHS Foundation Trust, Harrogate, United Kingdom; E. A. Eady,
Harrogate and District Hospital NHS Foundation Trust, Harrogate, United
Kingdom; Raed El-Naes, Harrogate and District NHS Foundation Trust,
Harrogate, United Kingdom
Resistance in Propionibacterium acnes (P acnes) is a worldwide problem,
especially to macrolide-lincosamide-streptogramin B antibiotics (65% of patients
colonised) and less so to tetracycline (20-30%). Antibiotics remain the mainstay of
treatment for acne and there are studies to demonstrate that harbouring resistant
strains of P acnes is associated with reduced efficacy to antibiotic therapy. The use
of’antibiotics also drives the resistance in the resident bacterial flora of the skin and
mucosa. In response to these concerns, there have been concerted efforts over the
last few years to rationalize antibiotic prescribing in acne by avoiding the use of
macrolides and instead’using tetracyclines, adopting regimes to include benzoyl
peroxide alongside antibiotics as an antiresistant agent and topical retinoids to
expedite efficacy and minimise antibiotic exposure. The aim of this study is to assess
whether the incidence of resistance in P acnes has changed particularly in the
context of recommended guidance on antibiotic usage in acne which now
advocates tetracyclines over macrolides as well as methods to reduce the likelihood
of resistance developing. 436 patients referred to a secondary care dermatology
department had P acnes cultured from acne affected areas. The swabs are inoculated
on Columbia blood agar and then WilkinseChalgren anaerobe agar. The plates are
incubated at 378C for 1 day and 7 days, respectively. Sensitivities to erythromycin,
clindamycin and tetracycline were assessed. The results from these cultures were
correlated with prescribing habits. This study will demonstrate the current numbers
of patients affected by resistant P acnes in this population, indicate whether
tetracycline-resistant P acnes are more common following recommended guidance
and provide some further indication on need for improved antibiotic prescribing
and / or need for alternative therapies at a time when awareness on antibiotic usage
is paramount.
Characterization of patients’ quality of life and experience in the course of
acne treatment
Robert Skaggs, II, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Emily Hix, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Karen Huang, MS, Wake Forest School of Medicine, Winston-Salem, NC,
United States; Steven Feldman, MD, PhD, Wake Forest School of Medicine,
Winston-Salem, NC, United States
Background: While quantitative studies demonstrate that acne impacts quality of
life, there is a relative lack of qualitative studies that provide complementary and
more detailed data.
Objective: The purpose of this study was to learn patients’ impressions of quality of
life and personal experiences in the course of an acne treatment.
Methods: Video interviews of 27 teenagers and young adults with acne enrolled in a
12-week clinical trial of adapalene/benzoyl peroxide gel were transcribed.
Transcripts were then coded using Weft QDA software and qualitatively analyzed.
Results: Four thematic domains were found in all participants that affected quality of
life and experience: physical symptoms of disease, self-perception, social placement
and perception of control. Successful treatment resulted in increased self-esteem
and better performance at work and school. Increased perception of control was
associated with increased quality of life and overall treatment satisfaction.
Conclusions: Successful acne treatment increases patients’ quality of life by
improving physical appearance and self-perception, satisfaction with social placement and perception of control. Psychosocial support in acne treatment, which can
include an emphasis on patients acquiring an internal locus of control, may improve
patient satisfaction.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
Commercial support: None identified.
P8403
Biomarker expression reflects the cyclical nature of rosacea in subjects
treated with oral doxycycline modified release
Anna Di Nardo, MD, PhD, Department of Medicine-Dermatology Research,
University of California, San Diego, La Jolla, CA, United States; Adrienne M.
Badeaux, PhD, Galderma Laboratories, L.P., Fort Worth, TX, United States;
Eugene Y. Huang, MD, PhD, Therapeutics Clinical Research, San Diego, CA,
United States; Norman Preston, PhD, Galderma Laboratories, L.P., Fort Worth,
TX, United States; Richard L. Gallo, MD, PhD, University of California, San Diego,
La Jolla, CA, United States; Ronald W. Gottschalk, MD, Galderma Laboratories,
L.P., Fort Worth, TX, United States
While an estimated 16 million people suffer from rosacea in the US, the numerous
pathogenic factors believed to augment the inflammation of papulopustular rosacea
(PPR) remain unknown. One such factor is the innate immune response which
includes increased cutaneous levels of antimicrobial peptides and their proinflammatory peptide byproducts. These proinflammatory peptides are thought to be the
product of increased activity of cutaneous members of the kalikrein (KLK) family of
serine proteases, which can in turn be activated by proteolytic cleavage by certain
matrix metalloproteinases (MMP). While these biomarkers were identified in
advanced disease states, it was unclear whether effective therapy known to improve
PPR would result in modification of these biomarkers. Previously, it was determined
that MMP levels greater than or equal to 0.01RFU/s imply a ‘‘state of inflammation’’
based on mouse models. This study evaluated doxycycline 40 mg modified release
(MR) capsules efficacy, safety, and impact on inflammatory biomarkers in subjects
18 to 70 years old with PPR. Investigator’s global assessment, lesion count, and
biomarker levels by tape strips were evaluated. Subjects with MMP levels above 0.01
RFU/s at baseline had reduced MMP levels with doxycycline MR treatment.
Doxycycline MR treatment also maintained or reduced MMP levels in subjects
that improved clinically according to IGA score and lesion count. Subjects with MMP
levels below 001 RFU/s at baseline, but with clinical inflammatory markers, saw an
IGA score of clear or near clear as early as week 4 with doxycycline MR treatment
compared to placebo. Subjects with MMP levels above 0.01 RFU/s at baseline and
clinical inflammatory markers also saw a greater improvement in IGA scores with
doxycycline MR treatment compared to placebo. Additionally, the percent
reduction in inflammatory lesion counts were similar. Doxycycline MR was well
tolerated in both groups, above and below 0.01 RFU/s with most adverse events
reported as mild or moderate. The most common AEs were nausea, sinusitis, and
upper respiratory infection. MMP levels do not always reflect the clinical status of
the disease, but the baseline MMP levels may predict clinical treatment success
depending on where in the rosacea inflammatory cycle the MMP levels are when
treatment with doxycycline MR is administered.
Supported by Galderma Laboratories, L.P.
AB6
P8114
Common reasons why acne patients call the office
Lauren Barnes, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Amir Al-Dabagh, Wake Forest School of Medicine, Winston-Salem, NC,
United States; Steven Feldman, MD, PhD, Wake Forest School of Medicine,
Winston-Salem, NC, United States; William Huang, MD, MPH, Wake Forest School
of Medicine, Winston-Salem, NC, United States
Background: Communication between physicians and patients is essential to
provide proper medical care, and patients at times leave with questions that were
not sufficiently addressed during the visit. Patients call the clinic for additional
information, which can be disruptive to the flow of clinical care, delay proper
treatment, and reduce patient satisfaction.
Purpose: We examine the post-visit questions of acne patients to develop
interventions to improve patient education and reduce clinic call-backs.
Methods: A retrospective electronic medical record (EMR) chart review was
performed in the Wake Forest Baptist Health (WFBH) Dermatology clinic for visits
between October 1, 2012 and October 31, 2012. Acne patients were identified using
clinic visit notes, and their charts were reviewed for telephone calls to the clinic
occurring between October 1, 2012 and March 29, 2013. Notes were grouped into
seven categories.
Results: Of 315 acne patients, 31 (9.8%) called the clinic. Isotretinoin was the
subject of 66.7% of the calls, and half the calls regarding isotretinoin involved
questions about potential side effects while taking the medication. Calls that did not
refer to isotretinoin addressed topical acne medications, acne symptoms, and
pharmacy requests.
Limitations: The study involved one center, and email and fax correspondence was
not captured.
Conclusions: We found gaps in communication sufficient to require patients to call
in for support, specifically for oral isotretinoin treatment. Interventions to address
these questions can be expected to improve quality of care.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8119
P8669
Common use of prescription off-label therapy for acne in the pediatric
population <12 years old
Sonal Parikh, Wake Forest School of Medicine, Winston-Salem, NC, United States;
Scott Davis, Wake Forest School of Medicine, Winston-Salem, NC, United States;
Steven Feldman, MD, PhD, Wake Forest School of Medicine, Winston-Salem, NC,
United States
Efficacy and safety of subantimicrobial dose, modified release doxycycline 40 mg vs doxycycline 100 mg vs placebo in the treatment of severe
acne
Angela Moore, MD, Arlington Center for Dermatology, Arlington, TX, United
States; Alicia D. Bucko, DO, Academic Dermatology Associates, Albuquerque,
NM, United States; Joyce Hwa, RN, Galderma R&D, Inc, Cranbury, NJ, United
States; Mark R. Ling, MD, PhD, Newnan Deramtology, Newnan, GA, United
States; Susan Qi, MS, Galderma R&D, Inc, Cranbury, NJ, United States; Vasant
Manna, MD, Galderma R&D, Inc, Cranbury, NJ, United States
Background: Acne is occurring more frequently in younger age groups, but most
available treatments are considered ‘‘off-label’’ in young children. Regulators have
been slow to adapt to the changing epidemiology of acne and expand the indication
to include younger age groups.
Objective: To analyze the frequency of off-label acne treatment by age and other
demographic factors.
Methods: We searched the National Ambulatory Medical Care Survey (NAMCS) for
1993-2010 for visits in children aged under 12 for the diagnosis of ICD-9 code 706.1.
We tabulated leading acne treatments and assessed factors associated with off-label
prescribing.
Results: Off-label but appropriate acne treatments were used in 29% of acne visits for
children under 12. Dermatologists were more likely to prescribe off-label treatment
than pediatricians (P \.0001). The most frequent off-label treatments used were
topical retinoids, followed by oral antibiotics. There was no significant trend in the
rate of off-label prescribing over time (P ¼ .4).
Limitations: The data reflect numbers of visits and not a direct measure of incidence
or prevalence.
Conclusions: Off-label treatment is well within the standard of care for young
children with acne. More data on the use of topical retinoids in young children may
help optimize treatment outcomes.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
Background: Doxycycline (DC) 100 mg is used in the treatment of moderate to
severe acne vulgaris, although routine use may be associated with patient safety and
public health issues, such as antibiotic resistance. Recent clinical data have
suggested that the use of subantimicrobial doses of DC may have the potential to
treat inflammatory lesions of acne with a lower risk of adverse events (AEs)
compared to antibiotic doses of DC.
Objective: Evaluate the safety and efficacy of subantimicrobial dose, modified
release DC 40 mg in the treatment of inflammatory lesions of acne compared to 100
mg DC (vs placebo).
Methods: This multicenter, randomized study included a total of 662 patients aged
12 years or older with moderate to severe acne and facial involvement (25-75
inflammatory lesions). Patients received DC 40 mg tablets (n ¼ 216), DC 100 mg
capsules (n ¼ 224), or placebo (n ¼ 222) once daily for 16 weeks. Efficacy
assessments included lesion counts (inflammatory, noninflammatory, and total) and
success rate (percentage of patients who achieved ‘‘clear’’ or ‘‘almost clear’’ score)
based on investigator global assessment (inflammatory).
Results: DC 40 mg was statistically superior to placebo in the reduction of the
number of inflammatory lesions (16.1 vs 12.6; P ¼ .006), percent reduction in
inflammatory lesions (51.6% vs 44.3%; P ¼.003) and total lesions (41.7% vs 34.1%; P
¼ .004), and success rate (14.4% vs 7.7%, respectively; P ¼ .025). A reduction in
noninflammatory lesions was observed vs placebo, but was not statistically
significant (10.0 vs 5.8, respectively; P ¼ .445). DC 40 mg showed superiority
compared to DC 100 mg in the reduction of the number of inflammatory lesions
(16.1 vs 12.9; P ¼.024), and percent reduction of total lesions (41.7% vs 35.9%; P ¼
.026), with nonsignificant numerical differences observed for percent reduction in
inflammatory lesions (51.6% vs 47.3%; P ¼.106), success rate (14.4% vs 13.8%; P ¼
.877), and reduction of noninflammatory lesions (10.0 vs 5.2, respectively; P ¼
.079). The incidence rate of drug-related AEs for DC 40 mg was similar to placebo
(3.7% vs 4.1%, respectively). The number of drug-related AEs was markedly smaller
for DC 40 mg compared to DC 100 mg (11 vs 50, respectively; nausea [3 vs 12],
vomiting [0 vs 14]).
Conclusions: DC 40 mg demonstrated comparable efficacy and superior safety
profile to DC 100 mg, with a comparable safety profile to placebo in the treatment of
moderate to severe acne.
Supported by Galderma Research & Development, SNC.
P8441
P8662
Effectiveness of adapalene/BPO gel in the first 4 weeks of treatment in
acne patients
Linda Stein Gold, MD, Dermatology Clinical Research, Henry Ford Health System,
West Bloomfield, MI, United States
Efficacy and tolerability of a topical treatment in adult female subjects
with mild to moderate facial acne and postinflammatory lesions
Elizabeth Makino, MBA, SkinMedica, Inc, an Allergan Company, Carlsbad, CA,
United States; Rahul Mehta, PhD, SkinMedica, Inc, an Allergan Company,
Carlsbad, CA, United States
Background: A fixed dose of adapalene/benzoyl peroxide (stabilized in the Simulgel
vehicle) Gel 0.1%/2.5% has been shown in previous studies to be efficacious in the
treatment of acne vulgaris. To help physicians and patients establish a realistic
treatment expectation for the first 4 weeks of therapy, a pooled analysis was
conducted to specifically evaluate the effectiveness and tolerability achieved in this
time frame.
Methods: Data from 14 studies, including 4 large vehicle-controlled studies (one
with patients as young as 9 years of age), were pooled to evaluate the effectiveness
and tolerability of adapalene/benzoyl peroxide gel 0.1%/2.5% among acne subjects
during the first 4 weeks of treatment. A total of 2,358 subjects between 9 years and
61 years old were treated with adapalene/BPO gel 0.1%/2.5%. In most of these
studies, adapalene/BPO gel 0.1%/2.5% was used for 12 weeks. Inflammatory lesion
counts, noninflammatory lesion counts, total lesion counts, and IGA scores were the
endpoints.
Results: Inflammatory, noninflammatory, and total lesion counts decreased with
adapalene/BPO gel 0.1%/2.5% use, showing a 40-50% reduction from baseline after
the first 4 weeks of use. Adapalene/BPO gel 0.1%/2.5% was well tolerated among
different skin types, ages, and genders, with most of the worst tolerability
assessments being none or mild.
Discussion: Adapalene/BPO gel 0.1%/2.5% was well tolerated and reduced
approximately half of the inflammatory and noninflammatory lesion counts at 4
weeks. The effects seen in the first 4 weeks from these studies are consistent with
those already demonstrated in individual vehicle-controlled studies. These observations provide a framework of expectations for adapalene/BPO gel 0.1%/2.5%
treatment during the first 4 weeks of treatment for clinicians to discuss with their
patients.
Dryness and irritation are common side effects associated with topical acne
treatments due to the presence of keratolytic ingredients such as tretinoin, benzoyl
peroxide, or salicylic acid. Although effective when consistently applied, tolerability
concerns linked to these ingredients may compromise patient compliance. Acne
lesions are also associated with the development of postinflammatory changes (ie,
postinflammatory hyperpigmentation [PIH] or postinflammatory erythema [PIE])
further aggravating the aesthetic concerns linked to this skin pathology. Therefore,
in an attempt to minimize unwanted acne-associated side effects, without
compromising efficacy, we have created a new topical formulation that contains
strong antioxidant and antiinflammatory ingredients as well as salicylic acid (2%)
and 4-ethoxybenzaldehyde. Tolerability and efficacy were evaluated by a 12 week
open-label, single-center clinical study. Female subjects aged 25 years and older with
mild to moderate facial acne and Fitzpatrick skin types I-V were included in this
study. Subjects were instructed to apply the acne lotion twice daily (morning and
evening) after cleansing. A target inflammatory lesion (TIL) and a target postinflammatory lesion (TPIL) were selected at baseline for further evaluation.
Investigator’s global assessment of acne severity (IGA), acne lesion counts, and
tolerability assessments (erythema, burning/stinging, dryness/scaling and itching)
were conducted at baseline, 24 and 48 h and at weeks 4, 8 and 12. The TIL was
assessed at baseline, 24 and 48 hours, while the TPIL was assessed at baseline and at
weeks 4, 8 and 12. Standardized digital photography were taken at all visits and a selfassessment questionnaire was performed at weeks 4, 8 and 12. Twenty-three female
subjects completed the 12-week study. Significant reductions in mean scores for IGA
and inflammatory lesion counts were observed at 48 h and weeks 4, 8 and 12 (P \
.02). Significant reductions in the TIL and TPIL occurred at all visits (P \.001). The
acne lotion was very well-tolerated with mean tolerability scores remaining below
mild. The study suggests that our new acne lotion may provide a comprehensive
solution for patients seeking an effective, nondrying treatment for mild to moderate
acne as well as postinflammatory lesions.
Supported by Galderma Laboratories, L.P.
Sponsored 100% by SkinMedica, Inc, an Allergan Company.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB7
P7748
P8383
Efficacy and tolerance of a novel topical composition on persistent
redness observed in patients treated with topical or oral therapy for
papulopustular rosacea
Hilary Baldwin, Sunny Downstate Medical Center, New York, NY, United States;
Christian Oresajo, L’Oreal Res. & Innovation, Clark, NJ, United States; Diane
Berson, New York - Presbyterian/Well Cornell, New York, NY, United States;
Margarita Yatskayer, L’Oreal Res. & Innovation, Clark, NJ, United States; Nannan
Chen, L’Oreal Res. & Innovation, Clark, NJ, United States; Yevgeniy Krol,
Skinceuticals Inc, New York, North Dakota, United States
Long-term efficacy and tolerance of a sonic brush and salicylic acid
cleanser for cleansing acneic skin
Katherine Ortblad, MHS, Pacific Bioscience Laboratories, Inc, Redmond, WA,
United States; Greg Peterson, PhD, Pacific Bioscience Laboratories, Inc,
Redmond, WA, United States; Robb Akridge, PhD, Pacific Bioscience
Laboratories, Inc, Redmond, WA, United States; Zoe Draelos, PA, MD,
Dermatology Consulting Services, High Point, NC, United States
Introduction: The delicate, compromised skin found with specific skin conditions
presents cleansing challenges. Removal of dirt, oil, & bacteria without harming the
function of the skin barrier are important when cleansing the skin.
Objective: To evaluate the safety & efficacy of an acne cleansing regimen (sonic skin
care brush, brush head designed for cleansing acneic skin, & 2% salicylic acid
cleanser).
Purpose of study: Objective was to determine the efficacy and tolerance of a novel
topical composition in patients who had been successfully treated with topical or
oral therapy for papulopustular rosacea but returned unsatisfied with their
persistent erythema.
Method: 25 subjects (23 women and 2 men) with papulopustular rosacea were
enrolled in this 8 week multicenter, open-label study. 24 completed the study. All
had been successfully treated for at least 6 weeks with at least one topical or oral
rosacea medication but were unsatisfied due to persistent moderate-severe facial
erythema. Subjects were asked to continue their previous rosacea medication and to
commence twice daily application of the study lotion. Cleanser was provided for
twice daily use before lotion application. Subjects were allowed to continue their
normal sunscreen and cosmetic use. They were asked not to change or add skin care
products during the course of the study. Clinician objective assessments of efficacy
and tolerability and patient subjective assessments were conducted at baseline
(before and after product application), and at weeks 4 and 8. Self assessment
questionnaires were distributed after in-office product application at baseline and
again at weeks 4 and 8. Clinician efficacy assessment included evaluation of
persistent redness (erythema), flushing during the visit, skin texture, radiance, skin
tone (evenness), overall rosacea severity and overall appearance on a 9 point scale
(0-4 with ½ point increments). Clinician tolerability assessment included evaluation
of dryness, edema, peeling and erythema on a 5 point scale (0-4). Patient subjective
assessments of tolerability included stinging, burning, tingling and itching.
Additionally, a self assessment questionnaire evaluated perceived improvement in
erythematic and rosacea symptomatology, overall skin quality and satisfaction with
the product. Digital photographs were captured on patients at baseline, week 4
week 8 for documentation purposes.
Results: Results demonstrated that the facial product was well tolerated and
significantly improved redness, flushing, overall papulopustular rosacea severity,
skin texture, radiance, skin tone evenness, and overall appearance.
Methods: 50 subjects between the ages of 18 & 60 with mild to moderate acne were
enrolled in this 12-wk study. Subjects using prescription acne medications for a
minimum of 6 months were enrolled as long as they continue to use the acne
medications for the duration of the study; had mild to moderate acne; & had oily
&/or acne prone skin. Subjects were instructed to use the cleansing regimen
whenever they cleansed their skin (morning &/or bedtime), not exceeding 2X/ day.
Safety was assessed before & after 2 wks of product use via investigator assessments
& measurements of Transepidermal Water Loss (TEWL), Erythema (E), & Hydration
[(H) Corneometry]. Efficacy & long-term safety were evaluated through investigator
assessments (global acne scale, 5 point ranking scale, 0 ¼ None & 4 ¼ Severe), &
user perception.
Results: Part I (safety): After 2 weeks of product use, TEWL measurements remained
in the range for healthy skin (10-15 g/m2/h) & no significant change in E & H were
measured (P ¼.77 & P ¼.28, respectively). Part II (efficacy & long-term safety): After
12 wks of product use, 92% of participants perceived the cleanser to be gentle on
their skin for daily use, 80% felt their skin was hydrated after use, & 88% saw a
reduction in the appearance of excess oil by at least 60%. Subjects additionally
reported decreased frequency, duration & severity of their breakouts (89%, 88%, &
80%, respectively). Wilcoxon signed-rank test of the investigator acne assessment
scores showed statistically significant improvement at 2 wks (average score of 1.8; P
\ .001), 6 wks (average score of 1.42; P \.001), 12 wks (average score of 1.24; P \
.001) when compared to baseline (average score of 2.4).Conclusions: The acne
cleansing regimen (sonic brush, acne brush head, & salicylic acid cleanser) is safe &
effective for daily cleansing of acneic skin.
Sponsored 100% by Pacific Bioscience Laboratories, Inc.
Sponsored 100% by L’Oreal.
P8622
Improvement in atrophic acne scars by topical adapalene (0.3% gel)
Manisha J. Patel, MD, John Hopkins University School of Medicine, Department
of Dermatology, Baltimore, MD, United States; Anna L. Chien, MD, John Hopkins
University School of Medicine, Department of Dermatology, Baltimore, MD,
United States; Fabien Audibert, MMSc, Galderma R&D, SNC, Sophia Antipolis,
France; Marie-Jos
e Rueda, MD, Galderma R&D, SNC, La Defense, France; Nabil
Kerrouche, MMSc, Galderma R&D, SNC, Sophia Antipolis, France; Sewon Kang,
MD, Department of Dermatology, Johns Hopkins School of Medicine, Baltimore,
MD, United States; Sherry Leung, RN, Johns Hopkins School of Medicine,
Baltimore, MD, United States
Background: Facial scarring is the most unfortunate and undesirable sequela of acne
which can greatly impact quality of life. Current treatment modalities for atrophic
acne scars are limited and require invasive procedures to improve appearance.
Studies on wrinkles have shown that topical retinoids stimulate collagen production
and increase epidermal thickness. Adapalene gel 0.3% e an effective agent for the
treatment of acne e has been shown to reduce fine and coarse wrinkles and may
potentially exert a beneficial effect in the treatment of atrophic acne scars.
Objective: Investigate the efficacy of adapalene gel 0.3% in the treatment of atrophic
acne scars.
Methods: This open-label, pilot study involved 20 patients aged 18 to 50 years with
moderate or severe facial atrophic acne scars. All patients received topical treatment
with adapalene gel 0.3% once daily for the first 4 weeks and twice daily for the
following 20 weeks. Assessment included global scarring grade, investigator (IGA)
and patient global assessment (PGA) for improvement in skin texture and atrophic
acne scars on the full face, atrophic acne scar counts on the skin surface area of
interest (SSAOI) e a 3-by-3 cm area containing at least 5 acne scars e as well as local
tolerability and Dermatology Life Quality Index (DLQI) questionnaire.
Results: According to full-face global scarring grade at baseline, the majority of
patients (60%) had moderate disease. At week 24, more than half of those (55.6%)
achieved 1-grade or 2-grade change from baseline (38.9% and 16.7%, respectively).
In addition, full-face IGA at week 24 showed at least marked improvement in skin
texture and atrophic acne scars in 50% of patients. Similarly, PGA for skin texture and
atrophic acne scars reported improvement in 83% and 89% of cases, respectively. In
the SSAOI, patients had an average of 19 atrophic acne scars at baseline. Atrophic
acne scar counts in the SSAOI at week 24 showed a 21.6% reduction from baseline.
Moreover, DLQI at baseline and week 24 revealed improvement, with all patients
experiencing little or no impairment on quality of life by the end of treatment (DLQI
mean score: 4.3 versus 1.3, respectively). Treatment was well tolerated.
Conclusions: Daily use of adapalene gel 0.3% for the treatment of atrophic acne scars
showed promising efficacy and improvement in quality of life. Further clinical
investigation is warranted to corroborate these findings.
Supported by Galderma R&D, SNC. Poster/editorial support provided by
Galderma Laboratories, L.P.
AB8
P8342
Minocycline weight-based dosing patterns and adverse event rates in
patients with acne vulgaris
Christina Cognata Smith, PharmD, MBA, Medicis Pharmaceutical Corporation,
Scottsdale, AZ, United States; Mandeep Kaur, MD, MS, Medicis Pharmaceutical
Corporation, Scottsdale, AZ, United States; Sham Chaudhari, MS, Xcenda, LLC,
Palm Harbor, FL, United States; Thomas J. Bramley, PhD, Xcenda, LLC, Palm
Harbor, FL, United States
Background: Minocycline is a common treatment for patients with acne vulgaris, but
it is associated with several adverse events. Appropriate weight-based dosing of
minocycline may minimize the frequency of adverse events. The primary purpose of
this study was to evaluate the relationship of average daily dose (ADD) and adverse
events for 3 minocycline products.
Methods: Patients aged 12e64 years with acne and treated with minocycline were
identified from a large electronic medical record database between January 2007
and August 2012. Patients were required to be continuously eligible for follow-up 6
months prior to and 6 months following the date of the first prescription for
minocycline (index date), have at least 1 ordered prescription for minocycline
within the enrollment period, and have at least 1 recorded diagnosis of acne within 1
month of the pre- or post-index date. ADD was calculated for each patient based on
strength, quantity supplied, days’ supply, and weight of patient. Patients with an
ADD between 0.9 and 1.1 mg/kg per day were deemed to be within the target dosing
range. In addition, 3 treatment groups were identified: minocycline IR (MIR),
generic minocycline ER (MER), and branded MER. Branded MER was distinguished
from generic MER, as there are more dosage strengths for branded MER than for
generic MER. Logistic regression was used to model the association between ADD
and several adverse events associated with minocycline (inflammatory bowel
disease, headache, fatigue, dizziness, rash, and diarrhea).
Results: There were 3,397 patients who qualified for study inclusion; 60 patients
received generic MER, 3,029 patients received MIR, and 308 patients received
branded MER. Overall, 10.8% of patients were within the target ADD range. Patients
receiving branded MER (45.8%) were significantly more likely to be within the target
ADD range than patients receiving MIR (7.2%) and generic MER (16.7%) (P\.0001).
Patients within the target ADD range were significantly less for headache (OR ¼
2.71; 95% CI: 1.17, 6.26) and fatigue (OR ¼ 1.81; 95% CI: 1.02, 3.20). Other
investigated adverse events did not meet statistical significance.
Conclusions: Minocycline dosed within the range of 0.9e1.1 mg/kg per day is
associated with a lower incidence of headache and fatigue. Greater variability in
dosage strengths seems to allow for better calibration of dosing based on patient
weight.
Supported by Medicis Pharmaceutical Corporation.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8432
P8068
Multicenter, randomized, double-blind, placebo-controlled evaluation of
rosacea related inflammatory biomarkers in papulopustular rosacea
adults treated with doxycycline 40 mg modified release
Eugene Y. Huang, MD, PhD, Therapeutics Clinical Research, San Diego, CA,
United States; Anna Di Nardo, MD, PhD, Department of Medicine-Dermatology
Research, University of California, San Diego, La Jolla, CA, United States; Norman
J. Preston, PhD, Galderma Laboratories, L.P., Fort Worth, TX, United States;
Richard L. Gallo, MD, PhD, University of California, San Diego, La Jolla CA, United
States; Ronald W. Gottschalk, MD, Galderma Laboratories, L.P., Fort Worth, TX,
United States
Overall tolerability of Epiduo from a pooled data analysis
Leon Kircik, MD, DermResearch, PLLC, Louisville, KY, United States
Rosacea affects millions of people in the US. It has previously been demonstrated
that rosacea has an inflammatory component. However, the seminal events which
are important in the development of this observation remain unknown. Factors
postulated to be associated with this observation include the augmented innate
immune response, increased cutaneous levels of antimicrobial peptides (AMPs)
including cathelicidins, increased activity of serine proteases, and up regulation of
certain matrix metalloproteinases. This multicenter, randomized, double blind,
placebo controlled study evaluated adults 18 to 70 years old with papulopustular
rosacea treated with placebo or doxycycline 40 mg modified release (MR) for 12
weeks. Specifically, clinical markers (lesion count and IGA) and biomarker levels
(skin tape strips and 2 mm skin biopsies) were evaluated. Treatment with
doxycycline MR treatment significantly reduced inflammatory lesions of rosacea
compared to placebo. Additionally, IGA success scores were significantly better after
treatment with doxycycline MR. Skin tape strip data showed that baseline
cathelicidin levels was a predictor of clinical success. Further evaluation of the
tape strip data also showed that subjects treated with doxycycline MR had
significantly lower levels of total protease activity at week 4 compared to subjects
in the placebo group. Subjects who experienced clinical success also had
significantly lower cathelicidin levels at weeks 8 and 12 compared to clinical
failures. Also, 2 mm skin biopsy data showed that total MMP levels were statistically
significantly lower at week 12 compared to baseline in the subjects categorized as
clinical successes. Doxycycline MR was safe and well tolerated by the subjects in this
study with mostly mild or moderate adverse events. In this study doxycycline MR
use produced similar clinical results to previous studies. Doxycycline MR also
affected rosacea associated biochemical markers, providing an avenue to further
explore the inflammatory component of rosacea.
Background: Epiduo (a fixed dose of adapalene/benzoyl peroxide stabilized in the
simulgel vehicle) gel 0.1%/2.5% has demonstrated effectiveness in the treatment of
acne vulgaris in several clinical trials. To further describe the tolerability of this
treatment, data were analyzed from several clinical studies that investigated the
effectiveness and safety of adapalene/BPO gel 0.1%/2.5%.
Methods: Data from 14 studies were pooled to evaluate the tolerability of
adapale/BPO gel 0.1%/2.5% gel among acne subjects. A total of 2,358 subjects
between 9 years and 61 years old were treated with adapalene/BPO gel 0.1%/2.5%.
Frequency, percentages, and worst postbaseline scores were summarized for
dryness, erythema, scaling, and stinging/burning.
Results: Most subjects experienced a worst postbaseline score of none or mild,
83.2% for dryness, 78.6% for erythema, 86.1% for scaling, and 76.8% for
stinging/burning. Two percent or fewer subjects had a severe score for dryness,
erythema, and scaling, and less than 5% of subjects had a severe score for
stinging/burning. Fewer than 2% of subjects discontinued due to an adverse event.
Even subjects with moderate and severe scores for the tolerability endpoints had
improved IGA scores from baseline to week 4.
Discussion: In this large pooled analysis, adapalene/BPO gel 0.1%/2.5% was well
tolerated and provided benefit even in subjects who had a less favorable tolerability
profile.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
P8043
P8511
Novel over-the-counter hydrogen peroxide based acne kit in treating acne:
Randomized, controlled, multicenter study of a hydrogen peroxide-based
acne system versus the benzoyl peroxide-based acne system in the
treatment of mild to moderate acne vulgaris
Rebecca Tung, MD, Loyola University Chicago - Stritch School of Medicine, La
Grange Park, IL, United States; Enzo Berardesca, MD, San Gallicano Dermatologic
Institute, Roma, Italy; Federica Dall’Oglio, MD, University of Catania, Catania,
Italy; Giuseppe Micali, MD, University of Catania, Catania, Italy; Jolinda Sinagra,
MD, San Gallicano Dermatologic Institute, Roma, Italy; Michael Nodzenski,
Loyola University Chicago - Stritch School of Medicine, La Grange Park, IL, United
States; Stefano Veraldi, MD, University of Milan, Milano, Italy
In this 8 week pilot study, 120 subjects (aged 14 years or older) with mild to
moderate acne vulgaris were enrolled to compare the safety and efficacy of a
hydrogen peroxide-based acne regimen (Acnekit, BMG Pharma) to a benzoyl
peroxide based regimen, (Proactiv, Gunthy Renker). One hundred and two patients
completed all study procedures and were analyzed. The primary outcome measure
of clinical response was documented with standardized digital photography and was
assessed using the Global Acne Grading System (GAGS) by blinded dermatologist
raters at baseline, 4 weeks and 8 weeks. A subject self-satisfaction questionnaire was
administered at week 8, and investigators were also queried at that time regarding
their assessment of safety and cosmetic benefit. Safety and tolerability of both
products were also measured by active elicitation regarding any adverse events from
patients at each visit, and recording of any adverse events noted by investigators.
Both treatment regimens were associated with improvement of GAGS score at 8
weeks compared to baseline (P \.0001). GAGS score did not differ significantly
between the two acne regimens over the same period (P ¼.7765). No adverse events
were reported by subjects or investigators for either treatment arm. Both subjects
and investigators found both acne regimens to be effective and cosmetically
acceptable, with no difference across arms reported by either (subjects: P ¼
.6994; investigators: P ¼ .6565). In summary, a hydrogen peroxide based acne
regimen was shown to be comparable in efficacy, safety and cosmetically
acceptability to a benzoyl peroxide based regimen for the treatment of mild to
moderate acne vulgaris.
Supported in part by a grant from BMG Pharma.
Papular scars: An addition to the acne scar classification scheme with an
exemplary case report
Stephanie Gan, MD, Boston University School of Medicine, Department of
Dermatology, Boston, MA, United States; Emmy Graber, MD, Boston University
School of Medicine, Department of Dermatology, Boston, MA, United States
Acne is one of the most common skin diseases, affecting over 90% of adolescents.
The severity of acne in adolescents increases with advancing maturity through the
teenage years. Although the prevalence and severity of acne scarring in the
population is not well documented, the available literature is usually correlated to
the severity of acne. Acne scars can present with varying morphologies. One
morphologic acne scar classification system includes 3 main types of scars: icepick,
rolling, and boxcar. Some have also used the term atrophic scars as a distinct entity
or as an all-encompassing term to refer to icepick, rolling, and boxcar scars. Other
less common scars include sinus tracts, hypertrophic scars, and keloidal scars.
Precise identification of the scar subtype is important in guiding therapeutic
management. We would like to expand the classification systems by adding papular
scars to the dermatologic lexicon. Papular scars are 3-4 mm skin-colored
cobblestone-like papules distributed anywhere on the body but, in our clinical
experience, most commonly on the back, nose, and chin. As an exemplary case, a set
of adolescent twins with moderate-to-severe acne developed morphologically
similar flesh-colored papules on the nose. These papules were initially misdiagnosed
as representing a granulomatous process and did not respond to standard acne
treatment. Biopsy of one nasal papule revealed scar tissue without evidence of
granuloma or acneiform lesion. Treatment with oral isotretinoin significantly
improved their acne, but these papular scars remained. As with other types of
acne scars, systemic therapy with antibiotics or isotretinoin is often required in
patients with papular scars to prevent further progression of disease. Papular scars
can clinically mimic closed comedones and granulomas, leading to an unnecessary
delay in appropriate treatment. A more specific and broader classification system is
important not only for obtaining an accurate clinical examination, but also for
designing targeted studies and treatment protocols for papular scars. Future
research should be directed towards comparative studies using scar treatments
such as subcision, punch excision, punch elevation, chemical peels and laser
treatments to determine the most effective approach to treating this newly classified
scar subtype.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB9
P7537
P8172
Quality of life in adult women with acne treated with 2 different
approaches
Marco Alexandre Dias da Rocha, MD, UNIFESP-EPM, S~ao Paulo, Brazil; Edileia
Bagatin, PhD, UNIFESP-EPM, S~ao Paulo, Brazil; Rachel Albuquerque, MS,
UNIFESP-EPM, S~ao Paulo, Brazil; Sergio Talarico Filho, MD, UNIFESP-EPM, S~ao
Paulo, Brazil
Safety and steady state pharmacokinetics of cortexolone 17a-propionate
(cb-03-01) 1% cream in adult subjects with acne vulgaris
Daniel Piacquadio, MD, Therapeutics Inc, San Diego, CA, United States;
Giuseppe Celasco, MD, Cosmo Research & Development, SpA, Lainate-Milano,
Italy; Luigi Moro, PhD, Cosmo Research & Development, SpA, Lainate-Milano,
Italy; Sandra Martha, MS, Therapeutics Inc, San Diego, CA, United States
Summary: Acne vulgaris is a chronic inflammatory disease that affects the pilosebaceous unit. Recent studies have demonstrated an increase number of acne cases in
adult women. These cases are predominantly normoandrogenic and have some
clinical differences when compared with the most common group, the adolescent.
The local glandular metabolism converts some hormonal precursors to more active
substances that increase the sebum production, leaving these areas more prone to
increase the colonization to Propionibacterium acnes (P acnes). Besides the
physical aspects, acne has a strong psychosocial impact and can lead to the onset of
signs and symptoms of depression and anger.
Objective: The objective was to analyze how the acne at postadolescent women
affects the quality of life and how the treatment can change this perception.
Background: Cortexolone 17a-propionate (CB-03-01, Cosmo SpA) is a steroidal
antiandrogen being developed for the topical treatment of acne vulgaris. In human
plasma, cortexolone 17a-propionate is rapidly metabolized to parent cortexolone,
an endogenous moiety readily found in human plasma.
Objective: Assess the safety and time to achieve steady state based upon plasma and
urine levels following topical application of CB-03-01 cream, 1% in adult subjects
with moderate to severe acne vulgaris.
Methods: The study group included 40 adult women with acne, without any other
sign of hyperandrogenism who were followed by six months at outpatient clinic of
Dermatology Division of the Hospital S~ao Paulo, Federal University of S~ao Paulo. This
group was randomized in 2 different groups. One did systemic treatment with oral
contraceptive and the other realized the treatment only with topical gel (azelaic
acid). At the first visit, all the patients received a standard questionnaire to analyze
the impact of the quality of life (acneQOL). After 6 months with the specific
treatment, the patients answered the same questionnaire. These data were statistic
analyzed.
Supported by Bayer (medication donations).
Methods: This single-center, open-label study assessed 8 adult (M&F) subjects over 6
weeks to determine the time to achieve pharmacokinetic (PK) steady-state of
cortexolone 17a-propionate and selected metabolites. Six (6) grams of the cream
was applied topically to the face and affected trunk areas QD for 42 days. Plasma
samples were taken prior to the 1st dose and at weekly intervals (24-hrs after the
prior day application) until Day 42. On Day 42 plasma samples were collected prior
to and 1, 2, 4, 6, 8, 12, 16 & 24 hrs after the final dose. 24-hour urine collections were
initiated post-dose at each weekly visit. Plasma samples were analyzed for concentration of cortexolone 17a-propionate & free cortexolone; urine samples were
analyzed for free and total levels of cortexolone 17a-propionate, cortexolone &
tetrahydrocortexolone.
Results: PK steady-state was achieved following the first application of CB-03-01 1%
cream; daily dosing caused no increase in plasma concentrations or urinary
recovery. At Day 42 systemic exposure levels were low. Minimum plasma
concentrations were quantifiable in 3 of the 8 subjects. Free cortexolone in plasma
and free cortexolone & tetrahydrocortexolone in urine were below the lower limit
of quantitation (BQL, \2.5ng/mL). There were two local skin reactions (LSRs)
reported in the study, and 5 of the 13 AEs reported were considered possibly related
to test article. All LSRs & AEs resolved without sequelae.’
Conclusion: PK results based on quantifiable plasma and urine data all indicate that
steady-state was achieved following the first application of CB-03-01 1% cream,
without evident accumulation, which may be a reflection of the low absorption and
the rapid metabolism of cortexolone 17a-propionate. No material safety findings
were noted in this study and the findings were consistent with prior CB-03-01
studies.
Supported by Cosmo Research & Development, SpA and Intrepid Therapeutics Inc.
P7957
Quality of life of patients with severe acne before and after treatment with
peroral isotretinoin
Zuzana Nevoralova, MD, PhD, Regional Hospital Jihlava, Jihlava, Czech Republic
Background: Acne is a chronic disease that frequently interferes with the quality of
life. Isotretinoin is the only therapeutic agent that exhibits effective activity against
all four main aetiologic factors. Successful treatment of acne may improve a patients
quality of life. To investigate this issue, we conducted a prospective, uncontrolled
study.
Methods: One-hundred and forty four patients were included in our single center,
no-blind, and no controlled prospective study. Before and after finishing of orally
administered isotretinoin, acne severity was assesed by grading and physical
dermatologic examination. All patients completed DLQI and CADI scores before
treatment and after finishing isotretinoin therapy. Statistic analyses of DLQI and
CADI scores were performed.
Results: All patients completed the study. 78% were men, 22% were women. 20%
suffered from severe acne papulopustulosa, 64% from acne nodulocystica and 26%
from acne conglobata. All patients were healed after isotretinoin treatment. Before
the treatment the mean DLQI score was 8.4 (8.2 for men, 9.8 for women), the mean
CADI score was 6,2 (6,2 for men, 6,3 for women). After finishing isotretinoin
treatment the mean DLQI score was 1.6 (1.6 for men, 1.6 for women), the mean
CADI score was 1.6 (1.6 for men, 1.4 for women). A significant improvement in both
DLQI and CADI scores was observed after isotretinoin therapy in the whole tested
group, and also in men and women separately. Significance was at P \.001 for the
whole tested group and at P \.001 for men and for women.
P7565
The prevalence of metabolic syndrome in patients with hidradenitis
suppurativa
Daniel Gold, Henry Ford Medical Center, Detroit, MI, United States; Iltefat
Hamzavi, MD, Henry Ford Medical System, Detroit, MI, United States; Meredith
Mahan, MS, Henry Ford Medical Center, Detroit, MI, United States; Virginia
Reeder, MD, Henry Ford Medical Center, Detroit, MI, United States
Background: Metabolic syndrome is a multifaceted disorder strongly associated with
increased risk for development of cardiovascular disease. Chronic inflammatory
diseases have been associated with metabolic syndrome. Hidradenitis suppurativa is
a chronic inflammatory skin disease with significant physical and emotional
sequelae.
Objective: To investigate a possible association between hidradenitis suppurativa
and metabolic syndrome.
Methods: A retrospective chart review of all dermatology clinic encounters over an
18 month period identified 366 subjects with an appropriate diagnosis of
hidradenitis suppurativa. A control population was created from subjects seen in
the same clinic during the same time period for the diagnoses of either keloids or
verruca vulgaris using the matching criteria of age 6 5 years, race, and gender. All
subjects were examined for characteristics of the metabolic syndrome as defined by
the National Cholesterol Education Program Adult Treatment Program III guidelines.
Results: The prevalence of metabolic syndrome in hidradenitis suppurativa patients
was 50.6%, which was significantly higher than the control group at 30.2% (P \
.001).
Conclusions: Our prospective study of patients treated with isotretinoin for severe
acne indicates that there is a deterioration of quality of life at most patients before
treatment. A significant improvement of quality of life was observed after successful
isotretinoin therapy in the whole tested group, and also in men and women
separately.
Limitations: This was a retrospective review. Some subjects could not be analyzed
for metabolic syndrome presence due to missing data points.
Conclusion: Our results indicate that hidradenitis suppurativa patients may be at
high risk for metabolic syndrome.
Commercial support: None identified.
Commercial support: None identified.
AB10
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8064
P8343
Tolerability and performance of a moisturizer with SPF 30 in acne subjects
undergoing treatment
Raymond L. Garcia, MD, RCTS, Inc, Irving, TX, United States; Michael Graeber,
MD, Galderma Research & Development, Inc, Cranbury, NJ, United States
Treatment failure of patients using topical acne treatments: An observational retrospective cohort study
S. Evan Carstensen, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Karen Huang, MS, Wake Forest School of Medicine, Winston-Salem, NC,
United States; Steven Feldman, MD, PhD, Wake Forest School of Medicine,
Winston-Salem, NC, United States
A 4-week, single center study (N ¼ 93) was conducted to determine the cutaneous
tolerability and performance of a moisturizer with SPF 30 (Galderma Laboratories,
L.P., Ft. Worth, TX) when used in acne patients, who were on acne treatments.
Subjects, aged 13-45 years, were instructed to apply the moisturizer once daily in the
morning while continuing their existing acne treatment. Cutaneous tolerability was
evaluated through changes in dermatologic signs (erythema, edema, dryness,
roughness and oozing on the face) and querying for symptoms (burning, tightness,
itching and stinging). Performance of the moisturizer on skin hydration was further
assessed on a subset of the population (n ¼ 30) by evaluating skin conductance at
day 7, day 14, and day 28 relative to baseline. Overall a significant decrease
(improvement), relative to baseline, in erythema values was observed after 7 days of
moisturizer use (P ¼.021). Significant decreases (improvement), relative to baseline,
in dryness values and in roughness values were also observed after 7, 14, and 28 days
of moisturizer use (P \.05). There was a significant increase in skin conductance
relative to baseline (observed on day 7 and lasting until day 28) indicating an
increase in skin moisturization. Tolerability was good with no significant changes,
relative to baseline, in the degree of burning, itching, stinging or tightness. Adverse
events reported by 21.5% of subjects were skin reactions which were deemed
related to the study products. All adverse events except for one were mild in severity
and most of them were transient, lasting a few seconds to a few hours. One reaction
was moderate in severity and led to study discontinuation (rash on the face). Overall,
once daily application of a moisturizer with SPF 30 was well tolerated and
significantly improved skin hydration of acne patients under treatment.
Supported by Galderma R&D, SNC. Poster/editorial support provided by
Galderma Laboratories, L.P.
Background: While limited data from clinical trials show differences in efficacy
between topical acne combination products and monotherapies, the effect of these
differences in clinical practice is not explored.
Purpose: To evaluate the effectiveness in clinical practice of prescribing combination treatments compared to monotherapy product(s) in minimizing treatment
failures.
Methods: Patients diagnosed with acne (ICD-9: 706.1) by a dermatologist between
January 2009 and September 2011and initially prescribed a topical acne treatment
were extracted from the Wake Forest School of Medicine’s Transitional Data
Warehouse. Multivariate Cox proportional hazards models were employed to
compare the hazards of treatment failure for patients initially prescribed a combination product vs. one monotherapy or multiple monotherapies. Subgroup analyses
were performed for specific drug combination products.
Results: 335 patients were initially prescribed topical product(s) exclusively. After
adjusting for patient age, sex, race and ethnicity, there was no evidence in differing
hazards of treatment failure for those prescribed a combination product compared
to those either prescribed one monotherapy product (HR ¼ 0.91, P ¼ .65) or
prescribed multiple monotherapy products (HR ¼ 0.73, P ¼.17). Those prescribed a
retinoid/benzoyl peroxide product had a nonsignificant lower hazard of treatment
failure (HR ¼ 0.85, P ¼ .61); whereas clindamycin/benzoyl peroxide had a nonsignificant higher hazard of treatment failure (HR ¼ 1.29, P ¼.33).
Limitations: Disease severity and treatments prescribed outside of the hospital
system were not available.
Conclusions: Treatment failures were consistent for patients prescribed combination product(s) or monotherapies. Patients prescribed combination retinoid/benzoyl peroxide products may have a lower hazard of treatment failure, but larger
studies are needed to confirm this effect.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
P8472
TPM/tretinoin formulations increase dermal tretinoin absorption and
reduce irritation compared to a commercial comparator formulation
Paul Gavin, PhD, Phosphagenics Ltd, Clayton, Australia; Biljana Nikolovski, PhD,
Phosphagenics Ltd, Clayton, Australia; Giacinto Gaetano, Phosphagenics Ltd,
Clayton, Australia; Mahmoud El-Tamimy, PhD, Phosphagenics Ltd, Clayton,
Australia; Ranelle Anderson, Phosphagenics Ltd, Clayton, Australia
Tretinoin is a leading prescription drug for the treatment of acne vulgaris. However,
tretinoin is poorly soluble, can be a teratogen at high plasma concentrations, and is
associated with skin irritation. A novel delivery technology comprised of different
forms of phosphorylated vitamin E, TPM, has been shown to have both antiirritant
and antiacne properties, as well as increasing the dermal delivery of poorly soluble
compounds into the skin after topical application. A series of human trials were
conducted to investigate whether TPM could increase the dermal absorption of
tretinoin without increasing systemic exposure, and to also examine the irritation
produced by these formulations. A phase I human trial used sequential tape
stripping in 12 subjects to investigate the dermal penetration of tretinoin in humans
following a single topical application of the commercial Retin-A cream (JanssenCilag, Australia) versus a TPM/tretinoin formulation. Blood was collected to measure
the plasma concentration of tretinoin. Topical application of TPM/tretinoin
significantly increased the average amount of tretinoin delivered into the upper
layers of the strata corneum (3.75-fold) when compared with the Retin-A
formulation. Despite the increased absorption, no tretinoin was detected in any
plasma samples above the limit of quantitation (4.66 ng/ml). A repeat insult patch
test (RIPT) was conducted in 27 subjects to compare the irritation produced by
TPM/tretinoin formulation versus Retin-A. Each test product was applied to the back
of each subject on a semi-occlusive patch every other day for the first week (Days 1
and 3), daily during the 2nd week (Days 8-11) and daily during the 3rd week (Days
15-18). The test materials were applied to the same site for each application. Patches
were worn for 24 hours and removed, before being assessed for irritation. Average
scores of erythema for TPM/tretinoin after 19 days of application were none-to-very
mild. By contrast, average erythema scores between mild-to-moderate were
generated by topical application of the commercial Retin-A cream. The differences
in erythema between formulations become significant (P \ .05) after 15 days of
application. A TPM/tretinoin formulation was able to increase the delivery of
tretinoin while reducing the irritation when compared to a leading comparator
product. TPM formulations are now being assessed in phase II clinical trials to assess
their potential to treat acne.
Supported 100% by Phosphagenics Ltd.
P8333
Treatment patterns and costs associated with acne in the United States
James D. Kendall, PharmD, Galderma Laboratories, L.P., Fort Worth, TX, United
States; Norman J. Preston, PhD, Galderma Laboratories, L.P., Fort Worth, TX,
United States
Acne vulgaris is a chronic skin disease affecting up to 87% of adolescents and over
50% of adults at some point in their lives. The monetary costs associated with acne
are high; over $2.2 billion was directly spent on acne OTC products, prescription
drugs, and office visits in the US in 2004. Despite the high prevalence and monetary
costs, there is a lack of published literature describing current treatment patterns
and comparative effectiveness assessments of prescription acne drugs. A retrospective study, using the IMS LifeLInkÔ Health Plan Claims Database, was conducted to
provide a description of current prescription drug patterns and healthcare utilization in acne. The study period was from January 1, 2009 to June 30, 2011. A total of
66,249 patients met the complete inclusion criteria and were included for study.
Most patients were female (58.3%) with a mean age of 17.9 years. Seventy-three
percent were on monotherapy which included combination products, topical
retinoids, oral antibiotics, or oral isotretinoin. An average of 60% of patients
prescribed a topical medication only had 1 prescription filled. The medical
possession ratio was 80.6% for oral isotretinoin compared to 27.8% for combination
topicals, 31.3% for topical retinoids, and 44.6% for oral antibiotics. Acne related
costs were highest for oral isotretinoin ($380 for medical; $2,439 for pharmacy).
Dermatologists were more likely to prescribe oral isotretinoin, oral antibiotics, and
combination therapy. Medical costs, pharmacy costs, and the number of physician
visits were also higher for dermatologists compared to nondermatologists. The
results of this study demonstrate that the prescribing patterns, medical costs, and
number of physician visits is different between dermatologists and nondermatologists. This is not surprising as dermatologists tend to be referred more complex and
treatment resistant patients.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB11
P8309
P7939
Treatment patterns and costs associated with rosacea in the United States
James D. Kendall, PharmD, Galderma Laboratories, L.P., Fort Worth, TX, United
States; Norman J. Preston, PhD, Galderma Laboratories, L.P., Fort Worth, TX,
United States
Rosacea is a chronic skin disease that affects an estimated 16 million people in the
US. Although skin disorders are one of the most common conditions for which
patients seek physician care, there is a paucity of literature describing treatment
patterns and compliance in rosacea patients. Recent published treatment patterns
were based on data from 2002 to 2005. Newer treatment options for rosacea have
since been approved making the published outdated. The aim of this study was to
describe current prescription drug patterns in rosacea including the proportion of
patients diagnosed with rosacea initiating drug treatment, the compliance with
various treatments, and to compare rosacea-related medical and pharmacy costs of
different treatments. This was a retrospective study that used the IMS LifelinkÔ
Health Plan Claims Database, which encompasses over 79 managed healthcare plans
covering over 70 million lives. A total of 99,894 patients met the inclusion criteria
and were included for analysis. Most patients were women (73.2%) with a mean age
of 52.4 years. Most (81.7%) were on monotherapy and topical medications were
most often prescribed (69.9%). Seventy percent of patients prescribed a topical
medication had only one fill. The medical possession ratio was 37.8% and 18.1% for
oral and topical medications, respectively. Rosacea-related medical and pharmacy
costs were highest for combination therapy ($70 medical; $536 pharmacy). Oral and
combination therapies were more likely to be prescribed by a dermatologist
whereas topical therapies were more often prescribed by nondermatologists.
Rosacea related medical costs were $73 for dermatologists and $33 for nondermatologists. Pharmacy costs for rosacea treatment were $343 for dermatologists
and $221 for nondermatologists. Not surprisingly, specialist care is associated with
more complex treatments and higher costs. However, the high one time fill of
topical medication suggests that patients self-dose based on self-diagnosis of rosacea
flares rather than in response to a specialist visit.
A full-face study evaluating the safety and efficacy of the lignin peroxidase
pigment lightening agent in Fitzpatrick skin types III-V
Mukta Sachdev, MD, MS, Cutaneous Research, Bangalore, India; Rachana
Shilpakar, MD, MS, Cutaneous Research, Bangalore, India
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
The desire for fair skin tone is very common among people with Fitzpatrick skin
types IV to VI. The need for efficacious and low undesirable side effects topical
formulations, that achieve pigment lightening, has become dermatologic challenge
worldwide, in view of the increasing incident of exogenous ochronosis. This
research study examined the topical efficacy of lignin peroxidase, an enzyme
derived from the tree fungus Phanerochaete chrysosporium in pigment lightening.
Lignin peroxidase as the active ingredient, which in the presence of hydrogen
peroxide oxidizes and degrades melanin formed in the skin, imparting fairness and
reduction of dyschromias. 40 female subjects mean age of 27.07 6 8.29 years with
Fitzpatrick skin types III (5.3%), V (31.6%), and IV (63.2%). All enrolled subjects
suffered from diffuse hypermelanotic disorders in different stages. All subjects
applied the Lignan Peroxidase Lotion (LPL) consistently on their entire facial area
twice daily during all treatment phase (84 days). The dermatology investigator
obtained shade card assessment and visual evaluation for skin clarity, skin tone,
homogenicity of dark spots, skin glow and radiance similarly; subject self-assessment
was conducted at each monthly visit. In addition, photography and target spot
Mexameter and Chromometer measurements were obtained. 38 subjects completed
the 12-week study (evaluation time points were 15, 28, 56, and 84 days). Site
application reaction was in low percentage and limited to itching, dryness,
acneiform eruption and oiliness. Following 12 weeks of LPL application improvement in glow and radiance of skin (P \.001), homogeneity of dark spots (P \.001),
even tone of the skin (P ¼.003), skin clarity (P ¼.002), and shade card assessment (P
\ .001) were statistically significant. This was confirmed by a statistically significant
reduction in melanin scores with the Mexameter readings (P ¼ .003), and
luminance/lightness chromameter analysis (P \ .001) at day 84 compared to
baseline. Subject self-assessment in which significant improvement in skin
moisturization (P ¼ .009) and radiance (P ¼ .024) was observed. This study
demonstrated that LPL may be considered as a useful alternative as a nonehydroquinone-based lightening agents for longer and maintenance therapy for
treatment of melasma and hyper pigmentation, especially in darker skin.
Supported by a research grant from Syneron.
P8117
A full-face study evaluating the safety and efficacy of a nonablative
minimally invasive radio frequency technology for wrinkle reduction
and skin laxity improvement
Macrene Alexiades-Armenakas, MD, PhD, Dermatology and Laser Surgery Center,
New York, NY, United States; Stefanie Luebberding, MS, New York, NY, United
States
The desire to turn back the signs of aging such as rhytides, dyschromia, elastosis, and
especially laxity is commonly sought in today’s aesthetic arena. The need for
efficacious and noninvasive procedure has become dermatologic challenge worldwide. Minimally invasive fractional radiofrequency technology creates thermal
effect denaturation and shrinkage of type I collagen during the insertion of 5 pairs of
electrically isolated needles into the dermis, causing collagen constriction and
neocolagenesis thereby improving skin laxity. This research examined the use of a
new treatment protocol performed at low temperature settings as compared to the
use of the high temperature protocol. The use of low temperature eliminates the
need for tumescence anesthesia and allows the procedure to be done with only
topical regimens. Fifteen white females (mean age 53 6 8 years) with observed
facial/neck laxity and wrinkles were randomized into 3 groups: nonablative RF
delivery raising temperature to (i) 50-618C (ii) 62-658C (iii) 66-678C. Each subject
underwent a single treatment (5 subjects in each group) and arrived to 3 and 6
month follow up (FU) visits. Subjects reported on mild pain during needle insertion
(1.6 6 2.0 in 0-10 scale) and during RF delivery (3.3 6 1.7). Similar pain levels were
reported within each group. Efficacy was assessed by AlexiadeseArmenakas
quantitative comprehensive scale (0-none; 4-severe). The analysis demonstrated
significant reduction in laxity (values of 3.0 6 1.6, 2.4 6 0.7, 2.3 6 0.7 for baseline,
3 and 6 month FU, respectively; P \.05). Consistent with these results, investigator
assessment of improvement in wrinkles, laxity and overall appearance was
significantly high (improvement rates of 73%, 93% and 93% for the 3 month FU
and 82%, 100% and 100% for the 6 months FU). Similar results were obtained by all
treatment groups. Subjects self-assessments showed high improvement rates for all
categories (87%, 80%, 80% at 3 month FU; 91%, 100% 73% at 6 month FU for
wrinkles, laxity, overall appearance respectively). Subjects’ satisfaction was high as
well reaching a level of 80% at the 6 month FU. No adverse events were observed
during the study. This study demonstrated that when using the minimally invasive RF
technology for wrinkle reduction and skin laxity improvement, lower temperature
settings are as good as the high temperature protocol with the added benefit of using
topical anesthetic creams only.
A novel at-home procedure providing marked improvements for lower lid
aesthetics utilizing a tensile, elastic, noninvasive polymer system with in
situ cross-linking functionality
Fernanda H. Sakamoto, MD, PhD, Harvard Medical School and Massachusetts
General Hospital, Wellman Center for Photomedicine, Boston, MA, United States;
Barbara A. Gilchrest, MD, Boston University School of Medicine, Department of
Dermatology, Boston, MA, United States; Betty Yu, ScD, Living Proof, Cambridge,
MA, United States; Mandy S. Su, Living Proof, Cambridge, MA, United States;
Nithin Ramadurai, MS, Living Proof, Cambridge, MA, United States; R. Rox
Anderson, MD, Harvard Medical School and Massachusetts General Hospital,
Wellman Center for Photomedicine, Boston, MA, United States; Soo-young Kang,
PhD, Living Proof, Cambridge, MA, United States
The Strateris technology is a first-in-class, topical transformative technology
platform for the management of skin disorders. In a randomized, split face study, a
Strateris polymer emulsion was applied unilaterally to the under-eye area of 12
volunteers with moderate to severe under-eye bags and allowed to cross-link, rapidly
forming an invisible film. Vehicle alone was applied contralaterally. A combination of
3-D digital photography (Canfield Vectra 3D) and optical coherence tomography
(OCT, Michaelson Diagnostics) was used to evaluate the tensile mechanical action of
the invisible Strateris layer on the target lower lid skin sites. In addition to the
average one-grade improvement in lower lid bag protrusion observed through
blinded evaluations of the 3D digital images (using a 0-4 photo-numeric scale), the
OCT images showed an increase of epidermal thickness, suggesting an increase in
the state of skin hydration. The ratio of the straight line distance and the
corresponding true epidermal surface roughness for the Strateris treated sites
more closely approached the value of one, compared to the ratio calculated for the
vehicle treated sites (0.98 6 0.0014 versus 0.96 6 0.0067, respectively). This result
confirms the visual assessment of a smoother skin surface with fewer irregularities 4
hours after Strateris versus vehicle alone application. The Strateris skin hydrating
properties were subsequently evaluated on the volar forearms of 17 volunteers,
where petrolatum was included as the gold standard reference, in addition to an
untreated control site. The transepidermal water loss (TEWL) values were measured
at baseline, 2 hours and 24 hours following test article application (cyberDERM RG1
Evaporimeter System). Compared to the untreated skin sites, Strateris and
petrolatum demonstrated significant reductions in the TEWL values at 2 hours
relative to the baseline values (-2.1 6 0.96 g/m2hr and -1.8 6 0.88 g/m2hr,
respectively; P \ 0.05). At 24 hours following test article application an average
decrease in the TEWL values persisted at the Strateris sites compared to the
untreated skin sites (-0.72 6 0.83 g/m2hr and -0.31 6 0.57 g/m2hr, respectively),
and the petrolatum exposed skin sites approached the TEWL values measured at the
untreated skin sites. These studies provide objective verification of the striking
aesthetic and hydration benefits of Strateris application to lower eye lids and suggest
that this platform technology may find many other dermatologic uses.
Supported by Syneron/Candela.
Supported by Living Proof.
AESTHETIC DERMATOLOGY
P8312
AB12
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8097
P8434
A novel ‘‘system’’ to aid the prevention of stretch marks during pregnancy: Results of a clinical trial, using a combination of a maternity
support device and synergistic cosmetic formulations
Fatima Malik, DPharm, The London Dermatology Centre, London, United
Kingdom; Jennifer Boone, MD, The London Dermatology Centre, London,
United Kingdom; Sunil Chopra, MD, The London Dermatology Centre, London,
United Kingdom; Sunit Ghatak, MD, The Portland Hospital, London, United
Kingdom
A randomized, double-blind, split-face comparative study of a novel
irritation-control retinol formulation versus tretinoin in photodamaged
skin
Elizabeth Makino, MBA, SkinMedica, Inc, an Allergan Company, Carlsbad, CA,
United States; Rahul Mehta, PhD, SkinMedica, Inc, an Allergan Company,
Carlsbad, CA, United States
Retinol has been shown to improve the appearance of photodamaged skin when
applied topically, and is generally considered to be approximately 10 times less
potent than tretinoin. To assess this theory, a novel sustained-release retinol
complex was specifically developed with a blend of antioxidants and antiinflammatory agents for optimal irritation control in 3 concentrations to correspond to
commercially available tretinoin strengths. A randomized, double-blind, split-face
comparison study was conducted to compare the 3 concentrations of the irritationcontrol retinol formulation (ICRe) including 0.25%, 0.5%, and 1.0%, against the
respective 3 strengths of tretinoin (0.025%, 0.05% and 0.1%) in subjects with
moderate to severe facial photodamage. Subjects were randomized into 3 groups:
group 1 (ICRe 0.25% vs. tretinoin 0.025%); group 2 (ICRe 0.5% vs. tretinoin 0.05%);
and group 3 (ICRe 1.0% vs. tretinoin 0.1%). Within each group, subjects were
randomized to apply ICRe on one half of the face (left or right) and tretinoin on the
other facial side, for a duration of 12 weeks. Clinical evaluations for efficacy and
tolerability, as well as standardized digital photographs were conducted at baseline
and at weeks 4, 8 and 12. Sixty-five subjects completed the 12-week study (group 1:
n ¼ 24, group 2: n ¼ 20, and group 3: n ¼ 21). At week 12 in all treatment groups,
both ICRe and tretinoin produced statistically significant improvements from
baseline in all efficacy parameters, including overall photodamage, fine lines/wrinkles, coarse lines/wrinkles, skin tone brightness, mottled pigmentation and
tactile roughness (all P \.001). There were no significant differences in efficacy
between ICRe and tretinoin in these efficacy parameters. Mean tolerability scores
remained mild or below for both treatments at all visits and there were no significant
differences between treatments. Results from this comparison study suggest that
this sustained-release retinol complex containing multiple agents for optimal
irritation control provides comparable improvements to tretinoin in the appearance
of photodamage.
Abstract: A first trial using a novel combination of synergistic topical creams and a
specifically padded, skin support device in the prevention of Striae Gravidarum.
Background: Striae gravidarum occur during pregnancy in 50% to 90% of women
and can be a cause of considerable cosmetic concern leading to significant
psychological distress. The striae initially appear as red or purple lines that gradually
fade, leaving white, thin skin. There are no treatments to date that have been shown
conclusively to prevent the development of striae.
Aim: To asses a novel combination of synergistic topical creams and a specifically
padded, skin support device using a novel alignment technology called Vector in the
prevention of striae gravidarum.
Method: Women in weeks 12-14 of their first pregnancy were recruited from the
Instituto de Maternidad Y Ginecologia, Tucuman, Argentina. The control group
consisted of women who used no creams or device and the treatment consisted of
women who used a combination of the device and day gel and night cream. The skin
support device was worn only during the day; the participants were recommended
to use the day gel twice daily and the night cream once, at bedtime. Photographs
were taken at the end of the first trimester and at term and assessed by 6
independent clinicians. A visual scale was determined with 0 being no striae and 10
being multiple striae.
Results: The incidence of striae gravidarum in the control group was 66%, while in
the incidence in the treatment group was 34%. The median severity score of the
control group was 7, whereas in the treatment group it was 4.
Conclusion: The systems combination of the specifically padded, skin support
device and creams has shown a significant reduction in the development of striae
gravidarum. The contribution to significance of each component has not been
trialed.
Supported 100% by SkinMedica, Inc, an Allergan Company.
Commercial support: None identified.
P7884
P8488
A prospective split-face double-blind randomized placebo-controlled trial
to assess the efficacy of vitamin C and ferulic acid serum postfractional
ablative laser for skin rejuvenation
Valeria Campos, MD, Universidade Medicina Mogi das Cruzes, Mogi das Cruzes,
Brazil; Denise Steiner, Universidade Mogi Cruzes, Mogi das Cruzes, Brazil;
Kamilla Denise Santos, MD, Universidade Mogi Cruzes, Mogi, Brazil; Ludmilla
Capucho, MD, Universidade de Mogi das Cruzes, Mogi das Cruzes, Brazil
Abstract: The topical use of vitamin C is considered to be effective to stimulate
fibroblast activity and hasten wound healing. We investigated the clinical efficacy of
vitamin C, vitamin E, and ferulic acid serum in wound healing and for improvement
in patient discomfort following fractional ablative laser surgery.
Objective: To determine whether vitamin C, vitamin E, and ferulic acid serum shows
efficacy immediately after fractional laser surgery and in the following week after
laser skin resurfacing in improving the severity and duration of postoperative pain,
erythema and wound healing.
Methods: Fifteen patients received a topical application of vitamin C, vitamin E, and
ferulic acid serum to randomly selected facial halves immediately after undergoing
full-face fractional laser skin resurfacing with 2940 nm erbium laser and twice a day
for 1 week after the laser treatment. All laser procedures were performed by a single
operator. Clinical improvement was evaluated by participants an two blinded
physicians by reviewing the comparative photographs. The rate of re-epithelialization, duration of pain, erythema, and presence of complications were recorded
immediately after the procedure and 1 hour, 24 hour, 2, 3, 4, 5, 7, 30, 60 days
posttreatment.
Results: The facial halves administered vitamin C, vitamin E, and ferulic acid serum
observed less pain duration in 60 % of the patients 1 hour after the initial application.
The erythema was more intense in the treated facial halves in 50% of the patients in
the day 1. The average time to reepithelialization was 3 days in the treated facial
halves and 4 days in the untreated facial halves. No side effects were observed.
Additional tests are ongoing to determine dermal remodeling by noninvasive
imaging analysis.
A randomized, evaluator-blinded, controlled study of the effectiveness and
safety of small particle hyaluronic acid plus lidocaine (SPHAL) for lip
augmentation
Frederic Brandt, MD, Dermatology Research Institute LLC, Coral Gables, FL,
United States; Mandeep Kaur, MS, MD, Medicis (a division of Valeant
Pharmaceuticals), Scottsdale, AZ, United States; Mark Nestor, MD, PhD, Center
for Clinical and Cosmetic Research and Department of Dermatology, University
of Miami, Aventura, FL, United States
Background: Voluminous lips are associated with youth and beauty, and are an
important aesthetic feature of the lower face. Small Particle Hyaluronic Acid plus
Lidocaine (SPHAL) has the same chemical composition as the 20 mg/mL family of
injectable hyaluronic acid gels currently approved in the United States and differs in
that the SPHAL gel particle is smaller. Thus, it may be ideally suited for lip
augmentation.
Conclusions: We believe that application of vitamin C, vitamin E, and ferulic acid
serum after fractional ablative laser skin resurfacing will make the procedure less
painful, enhance the natural wound healing process, and more quickly return the
patient to a pretreatment level of activity.
Objective: To compare the safety and effectiveness of SPHAL versus no treatment for
lip augmentation.
Methods: Adults (n ¼ 221; 18-65 y) scoring 1-2 on the validated Medicis Lip Fullness
Scale (MLFS; 1 ¼ very thin, 5 ¼ very full) for both lips were randomized (3:1) to
SPHAL or no treatment. Treatment success was defined as a blind-evaluated MLFS
increase ¼ 1 point at week 8. Secondary effectiveness assessments (lip fullness
augmentation and subject satisfaction) included the Global Aesthetic Improvement
Scale (GAIS) score at weeks 8, 12, 16, 20, 24 weeks; and 2, 4 weeks after optional 6month retreatment/treatment. Safety was assessed throughout the trial (adverse
events [AEs], standardized assessment of lip function).
Results: Overall, significantly more subjects treated with SPHAL for the upper lip
(80.2% v 11.9%), lower lip (84.2% v 18.4%) and upper and lower lips combined
(76.1% v 11.6%) were treatment successes at week 8, compared with subjects
receiving no treatment (P \.001 for all outcomes). GAIS response rates based on
subject and investigator assessments demonstrated significant improvement at
week 8 (90.1% and 96.5%, respectively [P \.001]) and week 24 (75.6%, and 83.8%,
respectively [P \.001]), for upper and lower lips combined. Treatment emergent
AEs (TEAEs) were less likely to occur in control subjects, compared with subjects
treated with SPHAL. Most common anticipated TEAEs in the initial SPHAL treatment
group included lip bruising, swelling, and pain, and were mostly mild or moderate in
severity. No anticipated device-related AEs or significant changes in lip function
were noted; few serious AEs were reported, and all unrelated to treatment. In
general, TEAEs were transient in nature and resolved in approximately 15 days or
less.
Conclusion: Treatment with SPHAL was effective and well tolerated for augmentation of lip fullness with improvement evident up to 6 months.
Commercial support: None identified.
Supported 100% by Medicis, a division of Valeant Pharmaceuticals.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB13
P8165
P8044
Assessment of level of evidence for cosmeceutical use in dermatology
Romi Bloom, Northwestern University Feinberg School of Medicine, Department
of Dermatology, Chicago, IL, United States; Antonella Tosti, MD, University of
Miami Miller School of Medicine, Department of Dermatology and Cutaneous
Surgery, Miami, FL, United States; Aurora Tedeschi, MD, PhD, University of
Catania, Dermatology Clinic, Catania, Italy; Dennis West, PhD, Northwestern
University Feinberg School of Medicine, Department of Dermatology, Chicago,
IL, United States; Giuseppe Micali, MD, University of Catania, Dermatology
Clinic, Catania, Italy; Nicole Larsen, Northwestern University Feinberg School of
Medicine, Department of Dermatology, Chicago, IL, United States
Clinical evaluation of the efficacy and tolerance of a body gel in
conjunction with laser hair removal on the legs
Amanda Dahl, L’Oreal Research & Innovation, Clark, NJ, United States; Margarita
Yatskayer, L’Oreal Resaerch & Innovation, Clark, NJ, United States; Michael Gold,
Tennessee Clinical Res. Center, Nashville, TN, United States; Nannan Chen,
L’Oreal Reseach & Innovation, Clark, NJ, United States; Susana Raab, L’Oreal
Research & Innovation, Clark, NJ, United States; Yevgeniy Krol, Skinceutical Inc,
New York, NY, United States
Introduction: Laser hair removal is one of the most common aesthetic cosmetic
procedures performed worldwide. Dry skin is also a common dermatologic effect
due to the thermal effect of the laser procedure. This study was designed to test the
efficacy and tolerance of a body gel containing Hydrovance, Hepes, Hyaluronic Acid
and Vitamin B3 in females undergoing laser hair removal on the legs.
Background: The cosmeceutical market is constantly expanding. While cosmeceuticals have both cosmetic and pharmaceutical effects, they are not regulated by the
Food and Drug Administration. Consequently, cosmeceuticals might not undergo
rigorous testing which may result in misleading claims about their risks and benefits.
Additionally, cosmeceuticals do not list active ingredients, but rather ingredients are
listed with respect to concentration.
Methods: A systematic PubMed search was conducted to identify published reports
of cosmeceutical agents for which the highest level of evidence (LOE) was assessed
using JAAD guidelines. The agents were categorized as follows: 11 antioxidants (eg,
vitamins A/B/C/E, selenium, ubiquinone), 2 growth factors (GF) (eg, epidermal GF
and transforming GF), 3 peptides (eg, signal, carrier, and neurotransmitter
modulating peptides), 22 botanicals (eg, oatmeal, olive oil, grape seed), 3 hydroxy
acids (HA) (eg, alpha/beta/poly HA) and 6 hypopigmenting agents (HPA) (eg,
hydroquinone, aloesin, kojic acid).
Results: A total of 114 citations were selected to determine the LOE for the 47
agents. For antioxidants, 33 LOE assessments were made for 11 agents, with the
highest LOE (Level IB) for retinoids and vitamin A derivatives, vitamin B, ubiquinone,
idebenone, eicosapentaenoic acid and kinetin. For GF, 4 LOE assessments were
made for 2 agents, with the same LOE (Level III) for both epidermal and transforming
GF. For peptides, 6 LOE assessments were made for 3 agents, with the highest LOE
(Level IIA) for signal peptides. For botanicals, 53 LOE assessments were made for 22
agents, with the highest LOE (Level IB) for grape seed, green tea, reservatrol, soy
isoflavones, curcumin, arnica, and lycopene. For HA, 6 LOE assessments were made
for 3 agents, with the highest LOE (Level IB) for beta HA. For HPA, 16 LOE
assessments were made for 6 agents, with the highest LOE (Level IB) for ellagic acid.
Conclusion: The LOE consisted of nonexperimental descriptive studies (Level III32% of citations) and evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both (Level IV-33% of citations). The risk to
benefit ratio could be improved if a higher LOE were to be obtained allowing
physicians to more confidently recommend cosmeceuticals to patients.
Methods: This randomized, double-blinded, 8-week clinical study included 22
female subjects aged 18-56 with Fitzpatrick types I or II and normally shaved legs
twice daily. Both legs were treated with a hair removal laser (Gentlemax Pro,
Syneron Candela) at the start of the study and a second time at 4 weeks. The body gel
test product was applied in a randomized manner to one leg; the other leg was
treated with a vehicle product. Subjects were evaluated for smoothness, dryness
(flakiness), skin tone (evenness), radiance, texture and overall appearance at
baseline (before the first laser treatment), day 3, week 4 (before laser treatment)
and at week 8. Additionally, subjects were evaluated at all the above time points for
objective and subjective tolerance as well as at immediate postlaser, postapplication
at the baseline and week 4 visits. Subject self- assessment questionnaires and digital
photography were also included in the study.
Results: The results showed that both the test product and the vehicle were effective
in improving the skin condition after 8 weeks of product use. However, for skin
tone, texture and overall appearance the test product showed better improvement
than the vehicle as early as week 4. For dryness and flaking, improvement was
similar in both products showing statistical significance by week 8. Immediately
after the first laser treatment the test product was not statistically significantly worse
in stinging and burning, unlike the vehicle treated leg that showed significant
worsening in both these attributes. This suggests that the test product reduces both
stinging and burning immediately postlaser, postapplication.
Supported 100% by L’Oreal.
Commercial support: None identified.
P7634
Clinical evaluation of the tolerance and efficacy of a topical tightening
treatment in conjunction with a radiofrequency procedure
Margarita Yatskayer, L’Oreal USA, Clark, NJ, United States; Christian Oresajo,
L’Oreal Research & Innovation, Clark, NJ, United States; David Goldberg, Skin
Laser and Surgery Specialists of NY & NJ, Passaic, NJ, United States; Nannan
Chen, L’Oreal Research & Innovation, Clark, NJ, United States; Susana Raab,
L’Oreal Research & Innovation, Clark, NJ, United States; Theresa Chen, L’Oreal
Research & Innovation, CLark, NJ, United States; Yevgeniy Krol, Skinceuticals
Inc, New York, NY, United States
Purpose: The objective of this study was to demonstrate the efficacy and tolerability
of a topical tightening treatment containing yeast extract, tripeptide, hydrolized rice
protein, microcrystalline cellulose and cellulose gum and LHA on skin laxity (loose,
sagging skin) on the posterior back thigh/buttock after both sides have been treated
with an established FDA approved device (Alma Accent XL).
Clinical evaluation of a topical treatment with ascorbyl tetraisopalmitate
nanoencapsulated, retinol, and glycolic acid in photoaged human skin
Jayme de Oliveira Filho, MD, Universidade de S~ao Paulo, S~ao Paulo, Brazil;
Carolina Holleben, Dermage Laboratories, Rio de Janeiro, Brazil; Neise Avelar,
Dermage Laboratories, Rio de Janeiro, Brazil; Simone Ribeiro, MD, Dermage
Laboratories, Rio de Janeiro, Brazil
Cutaneous aging is a complex biologic phenomenon in which there are biochemical, morphologic, and functional changes that lead progressively to the onset of
clinical signs that characterize aging. With age there are changes. Advances in skin
biology have increased the understanding of skin homeostasis of this organ and its
aging process, leading to the development of treatments and techniques in order to
prevent this mechanism and to rejuvenate the human body’s largest organ. This
article presenting clinical studies supporting the use of topically applied vitamin C
nanoencapsulated, glycolic acid and retinol for treating photoaged skin. One
hundred percent of the 31 healthy female volunteers (35-58 years old) with
actinically aged facial, neck, and forearm skin showed an improvement. The efficacy
of traditional active at high concentrations for prevention and treatment of
photodamaged skin were confirmed.
Methods: 20 white female volunteers between the ages 18 to 65 years with mild to
moderate loss of laxity (loose, sagging skin) on both back thigh/buttocks and those
who could not have a dramatic fluctuation in weight were enrolled in 8-week
double-blinded randomized clinical usage of tightening treatment on the back
thighs/buttocks in conjunction with a radiofrequency treatment procedure.
Volunteers applied the topical tightening treatment on the designated posterior
thigh/buttock twice per day. Other leg remained untreated. Baseline assessments by
a dermatologist included lifting, evenness of skin tone, radiance, skin texture,
firmness/tightness, and overall appearance using a 5 point visual scale. Objective
and subjective irritation symptoms were assessed using a 5 point scale at baseline
(pre- and post-laser post-application), Day 3 and Week 4 (pre- and post-laser postapplication) and Week 8. Measurements of both thighs, subjects weight and subjects
images of each posterior thigh/buttock were also obtained at the Baseline visit and
all follow up visits. Subjects received 2 radiofrequency treatments at Baseline and
Week 4. Volunteers completed self-assessment questionnaires at each study visit.
Results: Results demonstrated that the topical tightening treatment containing yeast
extract, tripeptide, hydrolized rice protein, microcrystalline cellulose and cellulose
gum and LHA showed significant improvements in all attributes assessed.
Additionally, when compared, the area treated with the Tightening treatment after
the radiofrequency procedure showed greater improvements than the area treated
with the radiofrequency procedure alone in skin tone (evenness), radiance and skin
texture after 4 and 8 weeks, and in firmness/tightness and overall appearance after 8
weeks.
Supported by Dermage Laboratories.
Supported 100% by L’Oreal.
P8385
AB14
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8552
P7841
Components of an over the counter antiaging cosmetic product result in
partial repair of photoaged skin as assessed by a short-term in vivo patch
test assay
Eleanor J. Bradley, The Dermatology Centre, Institute of Inflammation and
Repair, The University of Manchester, Manchester Academic Health Sciences
Centre, UK, Manchester, United Kingdom; Christopher E. M. Griffiths, The
Dermatology Centre, Institute of Inflammation and Repair, The University of
Manchester, Manchester Academic Health Sciences centre, UK, Manchester,
United Kingdom; Michael J. Sherratt, Centre for Regenerative Medicine, Institute
of Inflammation and Repair, The University of Manchester, Manchester Academic
Health Sciences, UK, Manchester, United Kingdom; Rachel E. B. Watson, The
Dermatology Centre, Institute of Inflammation and Repair, The University of
Manchester, Manchester Academic Health Science Centre, UK, Manchester,
United Kingdom
Efficacy of a total skin care approach using a combination of an antiaging
serum and a cream comprising a complex of growth factors for skin
rejuvenation
N. Rakotondrazafy, PhD, G.M.C. Medical/Laboratoires Dermo-Cosmetik,
Montreal, Quebec, Canada; L. Kassab, MD, G.M.C. Medical/Laboratoires
Dermo-Cosmetik, Montreal, Quebec, Canada; S. Denommee, MMSc, G.M.C.
Medical/Laboratoires Dermo-Cosmetik, Montreal, Quebec, Canada
Introduction: Growth factors are naturally occurring substances capable of
stimulating cellular growth and proliferation. Their topical use promotes skin cell
growth and tissue repair leading to visible skin rejuvenation, as demonstrated by
clinical trials. The present single center study investigated the efficacy and
tolerability of a total antiaging skin care approach comprising an antiaging serum
and a night cream.
Photoaged skin is characterized histologically by loss of fibrillin-rich microfibrils
(FRM) in the papillary dermis, a reduction in type I collagen synthesis (pCI). and
increased extracellular matrix protease activity. Whilst application of some over the
counter topical ‘‘antiaging’’ formulations can both improve the clinical appearance
of photoaged skin and induce FRM deposition, it remains unclear which ingredients
within a formulation are responsible for these benefits. In this study, we assessed
whether 4 components of an over the counter antiaging serum (Alliance Boots): a
matrix metalloproteinase (MMP) inhibitor alone and in combination with each of an
antioxidant mix, a blend of palmitoyl oligopeptide and palmitoyl tetrapeptide-7 or
retinyl palmitate, could induce deposition of FRMs and pCI and reduce protease
activity in a short-term assay which mimics long-term use. The efficacy of these
potential actives was assessed by comparison with the ‘‘criterion standard’’ clinical
treatment for photoaging, topical all-trans retinoic acid (tRA). Healthy but photoaged volunteers (n ¼ 8; 55-77 years) were recruited to the study. The aforementioned test ingredients were applied separately (blinded) under occlusion to
photoaged extensor forearm skin on each volunteer. Negative control was untreated
but occluded baseline skin. Formulations were applied over a 12 day period, with reapplication every 4 days; on day 8, tRA (0.025%) was applied as a positive control.
On day 12, 3-mm diameter skin biopsy specimens were taken from each site and
analyzed immunohistochemically for FRM and pCI whilst protease activity was
assessed via in situ gelatin zymography. In this cohort tRA, the MMP inhibitor alone
and in combination with the peptides induced deposition of FRM in the papillary
dermis (ANOVA; P \.001, P ¼ .011, and P \.001, respectively) whilst the MMP
inhibitor alone and in combination with the peptides also reduced protease activity
(ANOVA; P \ .05, P \ .05). Treatment with the MMP inhibitor also resulted in
deposition of pCI in the papillary dermis (ANOVA; P \.05). This study suggests that
some components found in over the counter ‘‘antiaging’’ formulations—either
acting alone or synergistically with other ingredients in an optimized unique
water/silicone delivery vehicle—may promote beneficial remodeling by altering the
balance between extracellular matrix protein degradation and production.
Methods: Both serum* and cream* contained a proprietary mixture of synthetically
bioengineered growth factors (EGF, IGF1, bFGF, and TGF1) and polypeptides.
Fifteen female subjects (all skin types), ranging from 35 to 75 years of age were
enrolled to test the system under in use conditions. They were asked to clean their
face/forearm with the supplied skin cleanser, to apply the serum followed by the
supplied hydrating cream with SPF15 in the morning and in the evening, after
cleansing to apply the night cream, over a 4- to 8-week period. Data were collected
during visits at baseline, day 14, 28, and 56 (end) evaluating skin condition of the
treated area, using a subject administered questionnaire for skin characteristics and
both subject and physician assessed product tolerance. The following assays were
used for evaluating skin condition: hydration,** transepidermal water loss,**
elasticity, firmness, and tonicity,** optical profilometry,*** and digital imaging.****
Statistical evaluation was performed independently, tests were carried out at the 5%
significance level and a confidence interval of 95% (P ¼ .05).
Results: Subjects reported already at day 14 a market improvement (60%) in their
skin condition for all the attributes assessed. The assay results showed similar trends.
When comparing baseline versus day 14 there was an increase in hydration level, up
to 26% on face and 20% on the forearm, a decrease in TEWL value, up to -18%, and an
improvement of the firmness of up to 38%. Further profilometry and imaging
showed a reduction of lines and wrinkles of the forehead, nasolabial and eye
contours, respectively up to -61%, -63%, and -49%. No adverse reactions were
reported during the first step of the study to prove the tolerability of the system.
Conclusion: The first results of the study indicate the total skin care approach to be
beneficial in reducing facial aging signs supporting repair processes for effective
skin rejuvenation.
*GF (GM Collin); **Courage (Khazaka); ***Quantirides (Monaderm); ****Visia
(Canfield).
Supported with a scientific grant from GM Collin Skincare, Plattsburgh, NY.
Supported 100% by Alliance Boots, Nottingham, UK.
P8299
P7829
Duration of effect by injection volume and facial subregion for a
volumizing hyaluronic acid filler in treating midface volume deficit
Dee Anna Glaser, MD, St. Louis University School of Medicine, St. Louis, MO,
United States; Deepali Paradkar, PhD, Allergan, Inc, Santa Barbara, CA, United
States; Diane K Murphy, MBA, Allergan, Inc, Santa Barbara, CA, United States
Objective: To examine the effectiveness of a volumizing hyaluronic acid (HA) filler
(Allergan, Inc.) based on injection volume and facial subregion when treating agerelated midface volume deficit.
Methods: In a multicenter study, 15 Treating Investigators across North America
enrolled and treated 235 subjects with a volumizing HA filler for midface volume
deficit. Subjects could receive a touch-up treatment 30 days after the initial
treatment if needed to achieve optimal correction. Effectiveness was assessed on
the validated 6-point Mid-Face Volume Deficit Scale (MFVDS) by 2 blinded Evaluating
Investigators making independent live assessments of subjects at quarterly visits
through 2 years. Duration of effectiveness was calculated using a KaplaneMeier
estimate of probability of maintaining a 1-point or greater improvement on MFVDS
based on the average score of the 2 Evaluating Investigators.
Results: Over 90% of subjects were treated in all 3 facial subregions: zygomaticomalar region, anteromedial cheek, and submalar region. At initial treatment the
median injection volume of the HA filler was 1.5 mL each for zygomaticomalar and
anteromedial and 1.9 mL for submalar. For the 82% of subjects who received a touchup treatment 30 days later, the volumes were smaller (1.0, 0.6, and 0.8 mL,
respectively) for a combined total of 2.0 mL for zygomaticomalar, 1.9 mL for
anteromedial cheek, and 2.1 mL for submalar. When duration of correction by
injection volume quartiles was calculated for each subregion, it was observed that
for subjects who received a median of 1.9 mL in the zygomaticomalar region, the
median duration of correction in that region was 19 months. In anteromedial cheek,
a median volume of 1.7 mL led to a median duration of 24 months. In the submalar
region, a median of 2.0 mL resulted in a median duration of 15 months.
Conclusion: The volumizing HA filler for age-related midface volume deficit is
effective, with approximately 2 mL in a facial subregion providing correction that
lasts 15-24 months.
Supported by Allergan, Inc.
Efficacy of incobotulinumtoxinA for treatment of glabellar frown lines: A
post hoc pooled analysis of 2 randomized, placebo-controlled phase III
trials
Derek Jones, MD, Skin Care and Laser Physicians of Beverly Hills, Los Angeles,
CA, United States; Fredric Brandt, MD, Dermatology Research Institute, Coral
Gables, FL, United States; Jean Carruthers, MD, Carruthers Clinical Research,
Vancouver, British Columbia, Canada; Joel Cohen, MD, About Skin Dermatology,
Englewood, CA, United States; Rhoda Narins, MD, Dermatologoy Surgery & Laser
Center, New York, NY, United States; William Coleman, MD, Tulane University
Health Sciences Center, Metairie, LA, United States
Background: The superiority of botulinum neurotoxin type A formulations over
placebo for treatment of glabellar frown lines has been demonstrated in several
studies. However, these studies differed in a variety of criteria, including baseline
severity of the study population, the type of rating (live rating, rating from
photographs, photonumeric scales), doses applied, timing of assessments and,
more recently, with regard to definitions of responders mandated by the Food and
Drug Administration (FDA).
Objective: To analyze the efficacy and duration of effect of incobotulinumtoxin A for
the treatment of glabellar frown lines, using pooled data from 2 large, phase III
placebo-controlled trials and endpoints similar to those used in previous studies.
Methods: Subjects were 18 years of age or older with moderate or severe glabellar
frown lines treated with a single 20-U dose of incobotulinumtoxin A. The
incobotulinumtoxin A and placebo groups in the pooled analysis comprised 366
and 181 subjects, respectively. Efficacy was evaluated by investigator- and subjectassessed responder rates (equal to 1-point improvement compared with baseline),
mean score and mean change from baseline glabellar frown line severity score.
Results: At all follow-up visits, responder rates and the mean change from baseline
score (investigator- and subject-assessed) were significantly greater in the incobotulinumtoxin A group than the placebo group (P \ .0001). The maximum
investigator-assessed responder rate (93.1%) was achieved at day 30 after treatment,
when the mean improvement on the 4-point facial wrinkle scale peaked at 1.88.
Although the effect of incobotulinumtoxin A treatment began to decline between
days 60 and 90, the responder rate was 45.7% at day 120 according to the
investigator assessment.
Conclusions: Results confirmed the superiority of incobotulinumtoxin A over
placebo for the treatment of glabellar frown lines, and the long duration of treatment
effect.
Supported by Merz Pharmaceuticals, LLC.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB15
P8180
P8448
Efficacy, safety, and subject satisfaction of pain management of a selfocclusive topical anesthetic cream for dermatologic laser procedures
Joel L. Cohen, MD, Aboutskin Dermatology, Lone Tree, CO, United States
Evaluation of a sonic applicator on skin elasticity and wrinkle analysis
compared to manual application and performance with 2 skin care
products
Greg Peterson, PhD, Pacific Bioscience Laboratories, Inc, Redmond, WA, United
States; Clara Jauquet, Pacific Bioscience Laboratories, Inc, Redmond, WA, United
States; Katherine Ortblad, MPH, Pacific Bioscience Laboratories, Inc, Redmond,
WA, United States; Katy Wisuri, Pacific Bioscience Laboratories, Inc, Redmond,
WA, United States; Lauri Tadlock, MD, Pacific Bioscience Laboratories, Inc,
Redmond, WA, United States; Shilpa Rapaka, MS, Pacific Bioscience Laboratories,
Inc, Redmond, WA, United States
Pain is a common patient complaint with dermatologic laser procedures. The
efficacy and safety of an FDA-approved topical anesthetic cream of lidocaine 7% and
tetracaine 7% (LT cream) has been evaluated for use before common laser therapies.
Efficacy, safety, and subject satisfaction with LT cream were assessed in 1 randomized, single blind study vs lidocaine 2.5% and prilocaine 2.5% cream (LP cream), as
well as 4 randomized, double-blind, placebo controlled studies. The study procedures were ablative laser resurfacing (N ¼ 20), nonablative laser resurfacing (N ¼
54), laser-assisted hair removal (N ¼ 60), laser treatment of vascular lesions (N ¼ 80),
and laser assisted tattoo removal (N ¼ 63). LT cream and LP cream or vehicle were
applied for either 20, 30, or 60 minutes depending on the procedure. Subjectreported VAS pain scores were significantly lower for LT cream than the comparator
(P \.001). Significantly more subjects were rated by investigators as having no pain
during procedures with LT cream than the comparator in all studies (P ¼ .001).
Similarly, significantly more subjects as well as investigators reported adequate
anesthesia with LT cream (P \.004). Most subjects also indicated that they would
use LT cream for future procedures (P \.001). Most reported adverse events (AEs)
were mild in severity. Erythema and edema were the most common reported AEs for
the LT cream and comparator groups. The procedure was stopped because of pain
intolerance in 1 subject with LT cream and 4 subjects with placebo during
nonablative laser resurfacing. Collectively, these data indicate that treatment with
LT cream is effective in relieving pain during laser therapies and is well tolerated.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
Introduction and Objectives: To measure changes in skin elasticity and wrinkle
analysis around the eye area in two 12-wk, split-face studies assessing the performance of the sonic applicator (SA): (1) evaluating performance to manual
application (MA) of a skin care serum for the eyes, and (2) evaluating performance
of 2 skin care serums.
Methods: A SA has been developed to infuse skin care products more effectively &
evenly around the eye area than MA.
Inclusion Criteria: Women between the ages of 35 - 65 with visible signs of skin
aging. Study 1: Twenty-two women were enrolled in a study comparing application
of a study serum applied manually vs. with a SA. TX was randomized to left or right
eye area. Participants applied Serum A with the SA for 30 seconds using small,
circular overlapping movement; the same amount of serum was applied manually to
the opposite side. Study 2: Fifty-five women (ages 35 - 65) were enrolled in a 12-wk
study comparing 2 study serums applied with the SA. Serums (Serum A & B) were
randomized to left or right eye area. In both studies, participants were instructed to
use the products 23 daily.
Measurements and Analysis: Skin elasticity measurements (Cutometer; CourageKhazaka, Cologne, Germany) and photographs (VISIA CR; Canfield Sci, NJ) were
captured at each visit (baseline, 2, 4, 8, and 12 weeks). Wrinkle reduction was
analyzed using Vaestro Image Analysis Toolkit, v 2.0 (Canfield Sci). In each study,
data was statistically analyzed using paired t tests.
Results: Study 1: The side of the face randomized to SA had a greater improvement in
gross skin elasticity (R2). At 12 wks, the side of the face randomized to SA had a
significant improvement over baseline measurements (P ¼ .036). Serum A applied
with the SA resulted in a faster and greater reduction in wrinkle count with
significant differences at both 2 and 12 wks (P\.01 and P ¼.05, respectively). Study
2: With use of the SA, a significant increase in net skin elasticity (R5) was measured
on the sides randomized to Serum A compared to the Serum B at 8 & 12 wks (P ¼.01
and P ¼.05; respectively). Wrinkle count was reduced more on the Serum A side at 2
wks (P ¼ .04) with a greater & sustained reduction for Serum A.
Conclusions: These studies further support the performance of a SA.
Supported 100% by Pacific Bioscience Laboratories, Inc.
P8425
Evaluation of a sonic brush, cleanser, and clay mask on deep pore
cleansing and appearance of facial pores through a new image analysis
software methodology
Nina Koski, Pacific Bioscience Laboratories, Inc, Redmond, WA, United States;
Clara Jauquet, Pacific Bioscience Laboratories, Inc, Redmond, WA, United States;
Emily Henes, Pacific Bioscience Laboratories, Inc, Redmond, WA, United States;
Katy Wisuri, Pacific Bioscience Laboratories, Inc, Redmond, WA, United States;
Lauri Tadlock, MD, Pacific Bioscience Laboratories, Inc, Redmond, WA, United
States; Shilpa Rapaka, MS, Pacific Bioscience Laboratories, Inc, Redmond, WA,
United States
Introduction: A sonic brush which uses oscillations of more than 300 motions/second
was developed to gently and effectively cleanse better than one can by hand. In
response to customer for cleansing of pores and hard-to reach areas of the face,a
regimen consisting of sonic brush, deep-pore brush head (DPBH), cleanser, and clay
mask [CM (with fruit acids)] were evaluated for cleansing efficacy and pore refinement
utilizing a new image analysis software methodology for evaluation of visual pores.
P8188
Efficacy, safety, and subject satisfaction of pain management with a selfocclusive topical anesthetic cream for dermal filler injections
Joel L. Cohen, MD, Aboutskin Dermatology, Lone Tree, CO, United States
Patients may experience significant pain during filler injections. Topical local
anesthesia is frequently used to reduce this type of pain. A cream containing
lidocaine 7% and tetracaine 7% (LT cream) is FDA-approved to provide topical
anesthesia for dermatologic procedures. Efficacy, safety, and subject satisfaction
with LT cream compared to placebo were assessed in this multicentre, randomized,
double-blind, placebo controlled study. Seventy subjects received concurrent 30
minute applications of LT cream and placebo on the left or right treatment area
before receiving dermal filler injections. This study group comprised primarily
women (96%) who were white (94%) with Fitzpatrick skin types II to IV (81%) and a
median age of 50 years. Subject-reported mean visual analog scale (VAS) scores were
significantly lower for LT cream than placebo (P \.0001). Likewise, subjects were
rated by the investigators as having significantly less pain with LT cream (P \.0001).
Significantly more subjects (P ¼ .0052) and investigators (P ¼ .0013) reported
adequate anesthesia with LT cream. More subjects also indicated that they would
have LT cream applied for future procedures (P \ .009). No to mild erythema,
edema, and blanching occurred in both treatment groups. Sixteen adverse events
were reported. Only 1 AE (erythema) in the placebo arm was considered related to
the study treatment. LT cream is effective and safe as a topical anesthetic for dermal
filler injections.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
AB16
Objective: Evaluate the efficacy of a sonic DPBH, new deep-pore cleanser (DPC),
and CM through evaluation of the cleanliness of hard to reach areas of the face (ie,
dermatoglyphics, around nose, pores, etc.) and appearance of pore size.
Methods: 30 subjects were enrolled in a study assessing a deep pore regimen on the
pore clarity. Photographs (VISIA CR) were taken at baseline, after 1st use and over
the course of 2 wks use of a sonic brush with brush head designed for deep pore
cleansing, cleanser, and CM. Participants were instructed to cleanse their face with
the sonic brush and DPC 1 or 2X/day. Twice a wk, participants were also instructed
to apply a thin layer of mask, allowing it to dry for 15 minutes. The mask was
removed with the sonic brush & water. Pore Size and Total Area (Area of
pores/region assessed) were evaluated from VISIA CR photographs using the
Vaestro Image Analysis Toolkit, v 2.0 (Canfield, Fairfield, NJ).
Primary Inclusion Criteria: Women between the ages of 18 and 65 with large pores
on their cheeks.
Results: The measured pore count reduced significantly after baseline (BL)
treatment, wk 1, and wk 2 treatments when compared to BL (P \.01 for BL, wk
1, and wk 2, respectively).The measured total area of pores reduced significantly
after BL treatment, wk 1, and wk 2 treatments when compared to BL [54.9, 41.9,
39.3, 37.44 (P \.01) for BL, wk 1, and wk 2, respectively].
Conclusions: The sonic brush with DPBH and DPC is more effective at cleansing hard
to reach areas of the face than manual cleansing. When combined with the addition
of a pore-refining CM, the clarity and appearance of pores is improved through
objective assessment of pores using a new image analysis software methodology.
Supported 100% by Pacific Bioscience Laboratories, Inc.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8294
P7803
Evaluation of safflower oil on cellulitis and localized fat
Samanta Nunes, MD, Samanta, S~ao Paulo, Brazil
Extract from Cryptomphalus aspersa eggs significantly promotes skin
homeostasis and migration and survival of skin cells in vitro
Salvador Gonzalez, Dermatology Service, Memorial Sloan-Kettering Cancer
Center, New York, NY, United States; Angeles Juarranz, Biology Department,
Universidad Autonoma de Madrid, Tres Cantos, Madrid, Spain; Eduardo Reyes,
Universidad de Alcala, Alcala de Henares, Madrid, Spain; Maria Matabuena,
InnCells, Tres Cantos, Madrid, Spain; S. Lucena, Biology Department,
Universidad Autonoma de Madrid, Madrid, Spain
Background: Regenerative properties of skin decrease with age and the search for
substances that minimize cutaneous aging has been steadily increasing. A patented
natural extract from Cryptomphalus aspersa eggs has been developed which
carries out regenerative activities when applied topically.
Objectives: To study the in vitro effects of the C aspersa egg extract on skin
homeostasis and cell migration, as well as on cell-cell (E-cadherin, -catenin) and cellsubstrate (vinculin, 1-integrin) adhesion protein expression. Moreover, its effects on
cell survival and matrix metalloproteinases regulation were also explored.
Safflower oil is full of unsaturated fatty acids, such as omega-9 and omega-3, and
plays an important role in lipid metabolism. It has been shown that it can decrease
cholesterol levels. The objective of this study is to evaluate its potential effect on
cellulitis and localized fat. Twenty-two women were evaluated on 0, 30, 60, and 90
days regarding Body Mass Index (BMI), tights circumferences, photographic images,
and degree of cellulitis (NurnbergereMuller). Patients were instructed to maintain
regular dietary habits and physical activity, and no medication or procedure were
done during the treatment. They received 1.6 g of omega-9 (oleic acid) and 9 g of
omega-3 (linoleic acid). Results showed a reduction of the BMI between 0.1-0.9
kg/m2, weight losses between 0.5-3.2 kg after 90 days, and also a reduction on tights
circumferences of 0.3 to 8.8 cm after 90 days. Improvement of the degree of
cellulitis was also observed. The conclusion is that this study may show a positive
effect of the safflower oil on treating localized fat and cellulitis. More studies are still
required to validate this beneficial activity.
Methods: Human keratinocyte cell line (HaCaT cells) and primary dermal fibroblasts
(HF) were used. To test cell proliferation, colorimetric MTT assay was performed.
Cell migration was studued using wound-healing assays complemented with MTT
assays to avoid subjectivity in result quantification, whereas Western blot and
immunofluorescence microscopy were carried out to test the expression of
different cell adhesion proteins. ELISA and immunofluorescence were performed
to determine fibronectin, MMPs and collagen 1.
Results: C aspersa egg extract clearly promotes proliferation and migration of
HaCaT cells in a time and dose-dependent manner facilitating tissue homeostasis.
Moreover, treatment with C aspersa egg extract increases the migratory behavior
and the expression of adhesion molecules in both HaCaT and HF. Finally, C aspersa
egg extract also improves cell survival and promotes phosphorylation of FAK and
nuclear localization of beta-catenin.
Safflower oil was provided by FQM.
Conclusion: C aspersa egg extract promotes regeneration of epithelial tissue, being
more effective on fibroblasts than keratinocytes. The dermal effect seems supported
by significantly increasing collagen synthesis and fibronectin production. Moreover,
MMPs release is downregulated in both types of cutaneous cells. All these effects
suggest a potential clinical impact in skin rejuvenation and regeneration of wounded
tissues.
Supported by Industrial farmaceutica Cantabria SA (IFC SA).
P8314
Evolution of facial aesthetic treatment over 5 or more years: An international, retrospective, cross-sectional analysis of continuous onabotulinumtoxin A treatment
Alastair Carruthers, MD, Carruthers Clinical Research, Vancouver, British
Columbia, Canada; Conor Gallagher, PhD, Allergan, Inc, Irvine, CA, United
States; Sarah Darmody, Allergan, Inc, Irvine, CA, United States
P8367
Results: Of 207 patients included, 194 met criteria for the per-protocol analysis.
Patients were treated with onabotulinumtoxinA for a mean of 9.1 6 2.9 years (range,
5.0-16.8) and data were collected from 5112 treatments, of which 4402 were GL
treatments. Mean age at first injection was 46.3 6 9.9 years. The longer patients
were treated, the younger they perceived themselves to look. GL treatment
temporally preceded crow’s feet lines (CFL), followed closely by forehead lines
(FHL). Dosing in GL and CFL remained relatively stable over the period 1999 to 2012,
although FHL dose decreased. A majority of patients (85%; 165/194) received
treatment with fillers, of which 111 began, on average, 38 months after first
onabotulinumtoxinA treatment. The remainder received fillers previously (n ¼ 25)
or began in the same year (n ¼ 29). In addition to a cumulative increase in
onabotulinumtoxin A treatments in GL, FHL, and CFL over time, there were
increases in facial aesthetic treatments with injectable fillers, energy-based devices,
and prescription topical creams. AEs were infrequent, mostly mild in severity, and
declined markedly over the first year of treatment.
Conclusions: This study shows that continuous onabotulinumtoxin A treatments
over several years are safe and can be used in conjunction with other aesthetic
treatments. Patients receiving continuous onabotulinumtoxin A treatment
perceived themselves to look younger than their actual age.
Co-authors: N. Sadick, F. Brandt, A.R. Trindade de Almeida, S. Fagien, G. Goodman,
H. Raspaldo, K. Smith
Fractional erbium 2940-nm laser and acoustic pressure wave ultrasound
module for transepidermal delivery of cosmetic antiaging ingredients for
wrinkles and pigment changes: A randomized, split face side by side study
Stefanie Luebberding, MS, Dermatology and Laser Surgery Center, New York, NY,
United States; Macrene Alexiades-Armenakas, MD, PhD, Dermatology and Laser
Surgery Center, New York, NY, United States
Skin aging is a complex multifactorial process that comes along with the aging
process of the human body resulting in the development of facial wrinkles and
pigment changes on the skin surface. Numerous treatments, such as ablative or
factional laser therapy, or the use of cosmeceuticals have been used to treat these
skin aging signs. Recently, a device which combines two technologies has been
invented using a fractional ablative Er:YAG 2940-nm laser, creating micro channels
for transepidermal delivery (TED) of cosmeceuticals, in combination with an
acoustic pressure wave ultrasound (Impact) module for enhancing the penetration
of the cosmetic formulation beyond the dermoepidermal junction into the deep skin
tissue. The aim of this study was to evaluate the safety and efficacy of fractional
ablative Er:YAG 2940-nm laser combined with cosmeceuticals and impact technology in the treatment of wrinkle, and pigmented skin. Fourteen subjects were
included in this single site, open label study. The subjects were assigned to 2 split
face side by side treatments (21 6 2 days) and additional 1- and 3-month follow-up
visits. According to randomization, one side of the face was treated with the
fractional Er:YAG laser plus cosmetic formulations, while the other side was treated
with the fractional Er:YAG laser plus cosmetic formulations plus the Impact module.
Photographs were taken and reflectance spectroscopy was performed at baseline,
prior to each treatment and during each follow-up visit. Before the initiation of the
first treatment each subject underwent clinical evaluation. All subjects completed
the trial. The majority reported no or mild discomfort during treatment. Besides mild
to moderate erythema and edema right after the treatment, no severe adverse events
were observed during the study. Efficacy was assessed by Glogau Photodamage Scale
and GAIS evaluation. The evaluation demonstrated a reduction in wrinkle severity
from 3.25 to 2.6 and an improvement of the overall assessment. The TED concept of
2 technologies in combination—the fractional ablative Er:YAG 2940-nm laser for
perforation of the skin creating a passage for cosmecuticals delivery and impact
ultrasound module for cosmeceuticals enhancement—constitute a solution for
overcoming both barriers of stratum corneum and intercellular fluid in cosmeceuticals delivery into the deep skin tissues for multiple aging skin imperfections. The
treatment seems to be tolerable, safe, and effective.
Supported by Allergan.
Supported by Alma Lasers.
Objective: Assess the evolution of facial aesthetic treatment in patients receiving
long-term continuous treatment with onabotulinumtoxin A.
Study Design: This international, retrospective chart review included patients aged
¼ 18 years at the time of their first onabotulinumtoxin A aesthetic treatment and a
history of ¼ 5 years of continuous onabotulinumtoxinA treatments (yearly average ¼
2 treatments, including 1 glabellar lines [GL] treatment/year for ¼ 5 years). Medical
records were reviewed for facial areas treated with onabotulinumtoxin A, number of
treatments, dosage per facial treatment area, concomitant facial aesthetic procedures and treatments, and onabotulinumtoxin Aerelated adverse events (AEs),
thus providing extensive data on the progression of patients’ aesthetic treatments
and clinical trends during the period of widespread adoption of injectable aesthetic
treatments.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB17
P8248
P8112
Improvement in facial skin appearance by a cosmetic treatment regimen
with skin energizing technology: A full face clinical study
Frauke Neuser, PhD, Procter & Gamble Technical Centres, Egham, United
Kingdom; Denny Deng, Procter & Gamble, Beijing, China; Jay Tiesman,
Procter & Gamble, Mason, OH, United States; Jim Li, Procter & Gamble,
Sharonville, OH, United States; John Oblong, Procter & Gamble, Mason, OH,
United States; Mary Johnson, Procter & Gamble, Sharonville, OH, United States;
Mary Werner, Procter & Gamble, Sharonville, OH, United States
Objective: The objective of this study was to demonstrate improvements in visible
skin appearance after continuous usage of a 3-product cosmetic antiaging skin care
regimen containing broad-spectrum sunscreen with niacinamide (N) + glycerin (G)
and moisturizers containing skin energizing technologies including N, an olive oil
derivative (O), pal-KTTKS (P) antiaging peptide, and dill extract (D).
Mesotherapy for skin rejuvenation: Long-term ultrasound improvement
of the subepidermal low-echogenic band
Aurora Tedeschi, MD, PhD, Dermatology Clinic, University of Catania, Catania,
Italy; Alessandra Nuovo, MD, Dermatology Clinic, University of Catania, Catania,
Italy; Francesco Lacarrubba, MD, Dermatology Clinic, University of Catania,
Catania, Italy; Giuseppe Micali, MD, Dermatology Clinic, University of Catania,
Catania, Italy
Background: Mesotherapy with hyaluronic acid (HA) is a treatment approach
currently used in cosmetic dermatology for skin rejuvenation. High-frequency
ultrasound ([16 MHz) is a noninvasive technique that has been used to evaluate agerelated dermal changes. The presence and the degree of a typical subepidermal lowechogenic band (SLEB) are photoage-related: the lower the SLEB echogenicity, the
higher the photoaging. The aim of this study was to evaluate, through ultrasound
imaging, the effects of microinjections of HA on skin photoaging.
Methods: This was a 6-week, randomized, double-blind, vehicle controlled full-face
study in 100 Chinese females with protracted occupational UV exposure, 20-60
years old. Subjects were stratified by age group and prestudy UV exposure time (low,
medium and high). Control subjects (n ¼ 50) were nonesunscreen users and
continued their regular routine. Treated subjects (n ¼ 50) used an SPF 30 broadspectrum sunscreen with N + G and a serum with N + O + P + D in the morning and
the same serum plus moisturizing cream with N + O + P + D in the evening.
Measurements were taken at Baseline, Week 3 and 6. During each visit, after 20
minutes skin standardization, subjects washed their face and waited an additional 20
minutes for total dry out before full face images were captured by Real 3.0 and VISIA
gen4 and hydration was measured at the cheek and upper inner arm by using the
Corneometer.
Results: The product regimen with SPF 30 broad-spectrum sunscreen and skin
energizing technology significantly improved skin hydration on the face after 3 and 6
weeks. The product regimen significantly reduced spot and melanin area fraction
and improved skin color evenness compared to control after 3 and 6 weeks. After 6
weeks, skin was significantly lighter and less yellow (L and b respectively), while no
change in redness was observed. After 6 weeks, the product regimen improved fine
lines and pores directionally but this did not reach statistical significance likely
because subjects were not recruited for texture and pore issues.
Conclusions: Continuous daily use of a 3-product cosmetic antiaging product
regimen with an SPF broad-spectrum sunscreen and moisturizers with skin
energizing technology significantly improved the appearance of facial skin after 3
and 6 weeks of product use in Chinese women with protracted UV exposure.
Supported by Procter & Gamble.
Methods: Twenty-two women (mean age: 50.5 years, range 36-65 years) with clinical
and ultrasound signs of moderate photoaging were enrolled in the study. Treatment
consisted of multiple microinjections of HA salts of biotechnological origin (total
amount injected in each session: 20 mg/mL) on the face and on the dorsal surface of
1 hand, once weekly for 4 weeks and, successively, once monthly for 4 months (for a
total of 5 months of treatment, Group A) or 9 months (for a total of 10 months of
treatment, Group B). The dorsal surface of the other hand of each subject was
injected with saline solution with similar timing and used as control. In all subjects,
ultrasound was performed on a target area corresponding to the second metacarpal
web space of the hands just before and 1 week after each treatment to evaluate SLEB
echogenicity changes during treatment. Cross-sectional B-mode scans were obtained by a 22-MHz ultrasound system. For each examined field, the amplitudes of
echoes of single image elements (pixels) of the SLEB were ascribed to a numerical
scale (0e255) and mean gray values were quantified with ImageJ public domain
software.
Results: Eighteen women completed the treatment. After 5 weeks, ultrasound
increase of dermal echogenicity was observed in 13 subjects, with a significant mean
increase of pixel numbers of the SLEB from baseline of +24.3% vs +6.5% of placebo
(P \.01); after 5 months, the mean increase was +19.5% vs +6.5% placebo (P \.05).
In 6 out of 9 subjects who completed the 10-month treatment the mean increase was
+19.5% vs 0% placebo (P \.05).
Conclusions: Our study suggests that mesotherapy with HA is a helpful treatment for
skin photoaging, as confirmed by ultrasound results that showed significant changes
in SLEB density with time. These are likely related to an increased density or
rearrangement of dermal collagen fibers by fibroblast activation resulting from
treatment.
Commercial support: None identified.
P8438
P8546
Improvement in skin tone concerns by a 3-step cosmetic treatment
regimen: A full face clinical study
Denny Deng, PhD, P&G, Beijing, China; Alex Liu, PhD, P&G, Beijing, China;
Calvina Li, PhD, P&G, Beijing, China; Jim Li, P&G, Cincinnati, OH, United States;
Joe Kaczvinsky, P&G, Cincinnati, OH, United States; Mary Werner, P&G,
Cincinnati, OH, United States; Sarah Li, PhD, P&G, Beijing, China
Background: Topical Niacinamide (N), Hexyldecanol (H), Inositol (I) and NUndecylenoyl-Phenylalanine (P) have each proven to be clinically effective in the
treatment of various skin tone concerns, including hyperpigmentation, sallowness,
and uneven skin tone. The objective of this study was to assess the effectiveness of
combining these 4 ingredients into a single 3-step daily skincare regimen, complete
with broad-spectrum sunscreen protection.
Methods: A 6-week, randomized, double-blind, vehicle-controlled full-face study was
conducted in Xi’an, China, in Chinese females with protracted occupational UV
exposure, 20-60 years old. All subjects were nonesunscreen users in past 12
months. Control subjects (n ¼ 50) continued their regular routine. Treated subjects
(n ¼ 50) used an SPF 30 broad spectrum sunscreen with N, an essence with N + H + I
+ P, and a cream with N + H + I + P + glycerol in the morning and the same essence
plus moisturizing cream with N + H + I + P in the evening. Measurements were taken
at Baseline, Week 3 and 6. At each visit, respondents began with 20 minutes of skin
acclimatization followed by facial cleansing and an additional 20 minutes of a
complete dry out period before full face images were captured by Real 3.0 and VISIA
(4th generation). Hydration was measured at the cheek and upper inner arm using a
Corneometer.
Results: The tone-correcting regimen delivered significant improvements in skin
tone concerns, indicating that the combination of N + H + I + P is effective in
providing tone-appearance benefits, even in women with prolonged UV exposure.
Skin hydration was significantly improved after 6 weeks. The product regimen
significantly reduced spot area fraction. The regimen also improved skin color
evenness compared to control after 3 and 6 weeks. After 6 weeks, skin was
significantly lighter and less yellow (L and b respectively), while no significant
changes in redness was observed.
Methods of assessing cleansing efficacy of a sonic skin care brush
Emily Henes, Pacific Bioscience Laboratories, Inc, Redmond, WA, United States;
Greg Peterson, PhD, Pacific Bioscience Laboratories, Inc, Redmond, WA, United
States; Katy Wisuri, Pacific Bioscience Laboratories, Inc, Redmond, WA, United
States; Lauri Tadlock, MD, Pacific Bioscience Laboratories, Inc, Redmond, WA,
United States; Matthew Winterscheid, Pacific Bioscience Laboratories, Inc,
Redmond, WA, United States; Shilpa Rapaka, MS, Pacific Bioscience
Laboratories, Inc, Redmond, WA, United States
Introduction and Objectives: To assess cleansing performance between manual
cleansing (MC) a sonic cleansing brush (SCB) by utilizing surrogate models of dirty
skin [Dirty Skin Surrogates (DSS): include components of long-lasting makeup,
artificial sebum, ‘‘standard soil,’’ particulatemater/atmospheric pollution (PM), &/or
colorants].
Materials and Methods: Subjects were enrolled in several comparison assessments
utilizing a split-face study design. Each performance assessment compared 2
methods of cleansing (eg, sonic cleansing vs. MC, comparisons of speeds of the
sonic brush, etc) on the removal of DSS. PM levels were assessed pre- and
postcleansing through colorimetric measurements and image analysis of subject
photographs (Image J, NIH, Bethesda MD). 10 to 30 subjects were enrolled in each
comparison. Equal amounts of surrogates for DSS were applied to each cheek of
study participants by the study estheticians. Cleansing method was randomized to
the side of the face or treatment region in each comparison. Cleansing time and
amount of cleanser and water were standardized in each comparison.
Results: Cleansing comparisons of sonic cleansing to MC provided repeated
indication of significantly greater removal of surface debris and PM with use of
the SCB (P\.01). While the sonic brush removed up to 100% of the toughest surface
debris without altering the skin barrier, manual cleansing typically leaves more
DSS/PM on the skin. When using a robust DSS formulation in a cleansing comparison
of the 4 sonic speeds, Delta L*a*b* measurements found a 76% difference in ultimate
performance between the lowest & highest speeds of the sonic brush. Twenty
percent greater performance of speed 4 was found over speed 3 (P ¼ .03), 30%
greater performance of speed 3 over speed 2 (P\.01), and 26% greater performance
of speed 2 over speed 1 (P \.01).
Conclusions: Continuous daily use of a cosmetic skin tone-correcting 3-step product
regimen containing multiple tone-improving ingredients and broad-spectrum UV
protection significantly improved the skin tone appearance of facial skin after 3 and
6 weeks of product use in women with protracted occupational UV exposure.
Conclusions: The SCB systems have proven to be well received and beneficial in
cleansing skin and removing DSS/PM. While every speed of the sonic brush systems
provides a measurably greater performance to MC, each speed provides the
opportunity for further customization of the sonic brush as part an overall skin
care regimen. Future studies will evaluate additional clinical performance benefits of
the sonic brush.
Supported by Procter & Gamble.
Sponsored 100% by Pacific Bioscience Laboratories, Inc.
AB18
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8108
P8471
Multicenter pivotal study of the safety and effectiveness of controlled
tissue release for the treatment of cellulite
Michael Kaminer, MD, SkinCare Physicians, Chestnut Hill, MA, United States;
Deanne Mraz Robinson, MD, SkinCare Physicians, Chestnut Hill, MA, United
States; Patrick Coleman, IV, MD, Coleman Cosmetic and Dermatologic Surgery
Center, Metairie, LA, United States; Robert Weiss, MD, Maryland Laser Skin and
Vein Institute, Cockeysville, MD, United States; William Coleman, III, MD,
Coleman Cosmetic and Dermatologic Surgery Center, Metairie, LA, United States
Background: Tissue release has been a physician practiced procedure for treating
cellulite for decades, using manual tools. Covering large areas is tedious and the lack
of precision has led to inconsistent results and durability. As a result, this approach
has been limited in adoption. A novel system (Cabochon Aesthetics, Inc) has been
developed, which places the tissue under tension and provides precise depth and
area control of the release. The system was the subject of a FDA approved IDE
pivotal study for improvement in the appearance of cellulite.
Methods: Data from an initial feasibility study was used to refine the treatment
procedure and determine the number of subjects necessary to statistically power
appropriate endpoints. The pivotal study was a prospective, multicenter, nonrandomized open label safety and effectiveness study in 3 centers enrolling 55
subjects. All subjects served as their own control, underwent a single treatment with
the investigational system, and were followed at 3D, 14D, 1M, 3M, 6M and 1Y
intervals. Safety was assessed by an independent Data Safety Monitoring Board.
Effectiveness was evaluated (3M, 1Y) by a blinded, independent physician panel
using randomized (before/after) standardized professional photographs according
to a validated quantitative scoring system for cellulite severity.
Results: All safety and effectiveness endpoints were met. 100% of subjects were free
from serious adverse events attributable to the procedure. Treatments were well
tolerated and effects were minor and resolved quickly. Average improvement in the
0-5 point cellulite severity scale was 2.1 points (P\.0001; 97.5% LCL ¼ 1.9) and 93%
(LCL ¼ 85%) of treated subjects had improvement of at least 1 severity grade (none,
mild, moderate, or severe). The average rate of correct before/after selection in the
evaluation was 98%. Using the Global Aesthetic Improvement Scale (GAIS), the
evaluators rated 98% of the subjects as having noticeable improvement with 75%
having marked improvement or better. More than 85% of the subjects were either
satisfied or very satisfied with their appearance by 3 months and thereafter. In
addition, data from the feasibility study demonstrates durability of effectiveness
beyond 3 years.
Conclusion: Controlled release of tissue under tension and at precise depths leads to
visible and lasting improvement in the appearance of cellulite.
Oral administration of pycnogenol associated with sunscreen improve
clinical symptoms of melasma
Valeria Campos, MD, Faculdade de Medicina, Jundiai, Brazil; Luiza Pitassi,
UNICAMP, Campinas, Brazil
Background: Melasma is a common disorder, most commonly in women with
phototypes III-V, is often difficult to treat. Pycnogenol, an extract of the bark of the
French maritime pine (Pinus pinaster), has been reported to decrease the darkened
area and the pigment intensity of melasma. It contains a standardized mixture of
phenolic compounds as important constituents. Pycnogenol protects against
ultraviolet radiation and has the ability to inhibit tyrosinase activity and melanin
biosynthesis.
Objective: The aim of this study was to evaluate the clinical efficacy of oral
administration of Pycnogenol combined with daily sunscreen application in patients
with melasma.
Methods: The study enrolled 29 patients (28 women, 1 man) of Fitzpatrick skin
types II to IV with melasma facial. Pycnogenol tablets were prescribed at a dosage of
100 mg daily for a period of 2 months combined with daily application of a sun
protection factor 50-plus sunscreen. Clinical and instrumental evaluations for
improvement in pigmentation were conducted at baseline and at each subsequent
follow-up visit at 4 and at 8 weeks. The effects of treatment were evaluated by 3
physicians not involved in the study and by standardized digital photographs (VISIA;
Canfield Imaging Systems, USA) based on improvement of pigmentation and
reduction in melasma size. These were graded into 4 levels: not effective (0%),
moderately effective (0.1-25%), effective (26-50%), and highly effective (51-100%)
The patients were included in this study in the summer to avoid confusion of results
possibly caused by improvement of melasma during the winter season.
Results: A total of 27 women completed the study and 2 patients dropped out of
treatment. Blinded physicians assessment demonstrated that 48.14% of subjects
experienced 26% to 50% improvement in pigmentation after 2 months of treatment.
The results were graded as follows: not effective (11.11% - 3/27), moderately
effective (37.03% - 10/27), effective (48.14% - 13/27), and very effective (3.7% 1/27). Objective VISIA measurements confirmed these observations, demonstrating
a reduction in pigmentation. No adverse events were reported during the study.
Conclusion: The oral administration of pycnogenol combined with daily sunscreen
application should be added as an adjuvant to other treatments of melasma. The
long-term administration of pycnogenol probably would have been more effective
for clinical improvement of melasma.
Commercial support: None identified.
Cabochon Aesthetics, Inc fully funded this research study.
P8437
Noninvasive assessment of collagen deposition and inflammation in facial
skin using in vivo reflectance confocal microscopy following treatment
with a novel retinol complex and tretinoin
Lisa Goberdhan, SkinMedica, Inc, an Allergan Company, Carlsbad, CA, United
States; Elizabeth Makino, MBA, SkinMedica, Inc, an Allergan Company, Carlsbad,
CA, United States; Lora Colvan, SkinMedica, Inc, an Allergan Company, Carlsbad,
CA, United States; Rahul Mehta, PhD, SkinMedica, Inc, an Allergan Company,
Carlsbad, CA, United States
Recent advances in in vivo reflectance confocal microscopy (RCM) technology have
allowed for improved visualization of structural features in the epidermis and
papillary dermis because of an increase in image resolution and understanding of
image interpretation. Topically applied retinoids have been clinically shown to
mitigate fine lines/wrinkles and provide improvements in skin texture, tone, and
pigmentation irregularities. Histopathologic analysis of treated skin support these
clinical changes showing new collagen deposition and improved quality of elastic
fibers. However, research using RCM to observe these retinoid-induced structural
changes have been limited. To explore the use of RCM on retinoid-treated skin, a
pilot study was conducted to determine if the clinical affects from topical
application of tretinoin 0.05% and a novel sustained-release irritation-control retinol
complex 0.5% (ICRe) could be detected by RCM. Five male or female patients aged
49-64 years with moderate to severe facial photodamage completed the study.
Subjects were randomized to apply the ICRe product on one half of their face (left or
right) and the tretinoin product on the other side. Both investigator and subjects
were blinded to the treatment received on each facial side. Subjects returned to the
clinic at weeks 4, 8, and 12 and were assessed for overall photodamage, fine
lines/wrinkles, tactile roughness, skin tone unevenness, and mottled pigmentation.
Self-assessment questionnaires were completed at all follow-up visits. Standardized
digital photographs of the overall face and RCM images of a designated target
location (left and right) were taken at all visits. At week 12, both tretinoin and ICRetreated facial sides demonstrated at least a moderate (;50% improvement) or
greater grade of overall improvement. Reductions in mean efficacy parameter scores
were observed at as early as week 4 with continued reductions through week 12.
Increases in collagen deposition were observed in the RCM images in addition to
changes in inflammatory cells. Both treatments were highly rated in the subject
questionnaire. These results demonstrate the novel application of in vivo reflectance confocal microscopy as a non-invasive method to observe the structural
changes associated with clinical improvements in photodamage after treatment
with the novel irritation-control retinol complex and tretinoin.
Sponsored 100% by SkinMedica, Inc, an Allergan Company.
P8016
Platelet-rich plasma and fractional CO2 laser combination treatment for
face rejuvenation
Amalia Tsiatoura, MD, Amalia Tsiatoura, Athens, Greece; Anastasios Vekris, MD,
Cosmetic Derma Medicine, Athens, Greece; Dimitra Zafeiratou, MD, Cosmetic
Derma Medicine, Athens, Greece
Background: Fractional skin rejuvenation has gained increased interest since its
introduction. It is used for skin resurfacing, wrinkles and acne scars treatment, as
well as hyperpigmentation treatment. Platelet rich plasma (PRP) therapy is being
used for more than 20 years in medicine. It is used both in Clinical and in Cosmetic
Dermatology. PRP acts by accelerating the process of tissue healing through
releasing growth factors inside platelet granules. The present study is focused on
investigations of the clinical outcome by fractional CO2 treatments followed by PRP
therapy in skin rejuvenation.
Methods: A CO2 laser was equipped with a scanner enabling it to perform fractional
treatments with 49, 81, or 121 microthermal zones (MTZ)/cm2. Eighteen patients
participated in the study. Both face and neck were treated 4 times with 1-month
intervals using a spot density of 81 MTZ/cm2, a 1 cm2 spot, and a microbeam energy
of 40-60 mJ. During the same treatment, 5 mL of blood was collected by the patients
and was kept in 5-mL vaccum tubes containing 0.35 mL of 10% sodium citrate. The
collected blood was double centrifuged. The PRP was then pipette and activated by
0.05 mL of 10% calcium chloride solution to each 1 mL of PRP. Then, the
concentrated platelets were injected into the treated area in order to improve
healing procedures and skin rejuvenation. Follow-up was performed 2 months after
the last treatment.
Results: At the 2-month follow-up all patients reported a very fast healing in trauma
caused by fractional CO2 laser. They also reported a significant reduction in wrinkles
and 85% of the volunteers rated the reduction in visible perioral and periorbital
wrinkles to be fair, good or excellent. For reduction of irregular pigmentation, fair,
good, or excellent clearance was reported by 60% of the volunteers. Five patients
who suffered from acne scars reported an improvement of at least 25% in acne scars.
Conclusions: The combination of fractional CO2 laser and PRP treatment in skin
rejuvenation is a very promising technique. It minimizes the trauma caused by
fractional CO2 laser and demonstrates subjective improvements in wrinkles, skin
texture, hyperpigmentation, and acne scars.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB19
P7737
P8303
Randomized, double-blind, half-side comparison of a monophasic CPM
versus a biphasic NASHA dermal filler in the treatment of nasolabial folds
Heike Buntrock, MMSc, University of Hamburg, Department of Chemistry,
Division of Cosmetic Science, Hamburg, Germany; Gerhard Sattler, PhD,
Rosenpark Research, Darmstadt, Germany; Martina Kerscher, PhD, University
of Hamburg, Department of Chemistry, Division of Cosmetic Science, Hamburg,
Germany; Tilmann Reuther, PhD, University of Hamburg, Department of
Chemistry, Division of Cosmetic Science, Hamburg, Germany; Welf Prager,
PhD, Dermatologikum Hamburg, Hamburg, Germany
REFINE-2: A multicenter, double-blind, randomized, placebo-controlled
pivotal phase 3 study with ATX-101, an injectable drug for submental
contouring
Shannon Humphrey, MD, Vancouver, Canada; Daniel Lee, MS, Calabasas, CA,
United States; Frederic S. Brandt, MD, Coral Gables, FL, United States; Frederick
Beddingfield, MD, PhD, Calabasas, CA, United States; Patricia Walker, MD, Santa
Barbara, CA, United States; Paul F. Lizzul, MD, PhD, Calabasas, CA, United States
Background: ATX-101, a synthetic version of naturally occurring deoxycholic acid, is
a first-in-class, submental contouring injectable drug. When injected subcutaneously
into submental fat (SMF), it contours the submental region via focal adipocytolysis
(fat cell destruction) and a resulting expected local tissue response. REFINE-2 is the
second of 2 phase 3 studies conducted in the United States and Canada to evaluate
the efficacy and safety of 2 mg/cm2 ATX-101 in the reduction of SMF.
Background: Intradermal injection of hyaluronic acid (HA) is currently the criterion
standard to reduce the appearance of nasolabial folds (NLF). Numerous HA filler are
available, mainly differing in their physical characteristics. Aim of this study was the
comparative evaluation of the effects of a monophasic HA filler with Cohesive
Polydensified Matrix (CPM) technology with those of a biphasic stabilised hyaluronic acid-based gel of non-animal origin (NASHA) for treatment of NLFs on wrinkle
severity, surface topography and patient satisfaction.
Methods: A randomized, double-blind, half-side comparison study with 20 subjects
aged 35-65 years (NLF grade 3-4). Subjects received a single, contralateral, intradermal injection of a monophasic HA-filler and a biphasic HA-filler. Efficacy was
assessed at baseline, 2, 24 and 48 weeks using WSRS, GAIS (rated by investigator and
subjects), subject questionnaire (injection comfort, WSRS, GAIS and patient
satisfaction), Merz-Scale (rated by a blinded independent evaluator using photographs taken at each visit) and biophysical in vivo methods, such as surface
topography (PRIMOS).
Results: Data from 20 subjects (52 6 5.6 years) recorded a significantly less injection
pain for the monophasic HA-filler (P ¼ .011). Significantly improved patient
satisfaction was confirmed with both HA products up to 48 weeks, however, there
was a significant difference after 24 and 48 weeks in favor of the monophasic CPMfiller (P ¼.002; P ¼.005). Subject rated WSRS and GAIS as well as investigator rated
GAIS revealed significantly more improvement with the monophasic HA filler after 2
weeks (P ¼.012, P ¼.01, and P ¼.025), while after 24 and 48 weeks both products
showed similar significant effects. Independant Rater scored Merz-Scale showed
after 2 and 24 weeks similar significant effects with both products, while after 48
weeks just the CPMHA injected NLF showed significant improvements (P ¼ .034).
PRIMOS and investigator rated WSRS improved significantly with both fillers up to
48 weeks.
Conclusion: The single intradermal injection of a monophasic CPM and a biphasic
NASHA filler in a randomized, double-blind, half-side comparison study showed
significant improvements with both fillers up to 48 weeks combined with significant
differences in injection comfort, wrinkle severity, aesthetic improvements and
patient satisfaction in favor of the monophasic CPMHA filler.
Design: The study was conducted in 35 centers and enrolled 514 subjects with
moderate to severe SMF as rated by both clinicians and subjects. Subjects were
randomized (1:1) to receive subcutaneous injections of 2 mg/cm2 ATX-101 or
placebo into the SMF. Up to 6 treatment visits, approximately 1 month apart, were
allowed. As an objective measure of submental volume reduction, magnetic
resonance imaging (MRI) was performed on a 224-subject cohort. Primary and
secondary efficacy endpoints were assessed 12 weeks after the last treatment. The
study had 2 primary composite efficacy endpoints: the proportion of subjects with
simultaneous improvement of at least 1 grade and at least 2 grades from baseline,
respectively, on 2 validated scales, the Clinician-Reported Submental Fat Rating
Scale and the Patient-Reported Submental Fat Rating Scale. Secondary endpoints
were the proportion of subjects with a reduction of at least 10% in MRI-measured
volume and improvement from baseline on the Patient-Reported Submental Fat
Impact Scale. Additional efficacy assessments were evaluated at various time points
during the study. Adverse events and changes from baseline in vital signs and
laboratory values were recorded throughout the study.
Results: Data analysis from this completed phase 3 study is ongoing. Findings on
efficacy and safety endpoints will be reported at the time of presentation.
Conclusion: ATX-101 is the first submental contouring injectable drug to be
investigated in a rigorous clinical development program. To date, the program has
enrolled more than 2500 subjects. ATX-101 has been shown to be effective and well
tolerated in controlled phase 2 investigations and 2 European phase 3 studies.
Findings from multiple clinical studies suggest that ATX-101 may address patients’
unmet need for an injectable drug option to reduce SMF and improve their
submental profile as well as self-perceptions of appearance.
Support provided by KYTHERA Biopharmaceuticals, Inc.
Commercial support: None identified.
P8301
REFINE-1, a multicenter, double-blind, randomized, placebo-controlled
pivotal phase 3 study with ATX-101, an injectable drug for submental
contouring
Derek H. Jones, MD, Los Angeles, CA, United States; Daniel Lee, MS, Calabasas,
CA, United States; Frederick Beddingfield, MD, PhD, Calabasas, CA, United States;
Jean Carruthers, MD, FRCS(c), Vancouver, Canada; Patricia Walker, MD, PhD,
Santa Barbara, CA, United States; Paul F. Lizzul, MD, PhD, Calabasas, CA, United
States
Background: ATX-101 is a first-in-class submental contouring injectable drug. When
injected into subcutaneous fat, ATX-101, a synthetic version of naturally-occurring
deoxycholic acid, causes focal adipocytolysis (fat cell destruction) and a resulting
expected local tissue response. REFINE-1 is the first of 2 placebo-controlled, phase 3
studies to evaluate the efficacy and safety of 2 mg/cm2 ATX-101 in the reduction of
submental fat (SMF).
Design: Conducted in 35 centers in the United States and Canada, this double-blind,
randomized, placebo-controlled study enrolled 505 subjects with moderate-to-severe
SMF as rated by clinicians and subjects. Subjects were randomized (1:1) to receive
subcutaneous injections of 2 mg/cm2 ATX-101 or placebo into the pre-platysmal SMF.
Up to 6 treatment visits, approximately 1 month apart, were allowed. Magnetic
resonance imaging (MRI) was performed on a 222-subject cohort as an additional
objective assessment of submental volume reduction. Subjects were followed for up
to 24 weeks after the last treatment. Primary and secondary efficacy endpoints were
assessed 12 weeks after the last treatment. The 2 primary composite efficacy
endpoints were: the proportion of subjects with simultaneous improvement of at
least 1 grade and at least 2 grades from baseline, respectively, on 2 validated scales,
the Clinician-Reported Submental Fat Rating Scale and the Patient-Reported
Submental Fat Rating Scale. Secondary endpoints were changes from baseline in
MRI-measured submental volume and improvements from baseline on the PatientReported Submental Fat Impact Scale. Additional efficacy assessments included
other patient-reported outcome measures. Adverse events and changes from
baseline in vital signs and laboratory values were recorded throughout the study.
Results: Data from this completed phase 3 study are still being analyzed. Topline
findings on efficacy and safety endpoints will be reported at the time of presentation.
Conclusion: ATX-101 is the first submental contouring injectable drug to be
investigated for reducing submental fat in a rigorous clinical development program,
which to date has enrolled more than 2500 subjects. In 2 European phase 3 studies
and controlled phase 2 investigations, ATX-101 was effective and well tolerated.
Results from multiple clinical studies suggest that ATX-101 may address patients’
unmet need for an injectable drug option to improve their submental profile and
self-perceptions of appearance.
Supported by KYTHERA Biopharmaceuticals, Inc.
AB20
P8686
Results from a pivotal study on ArteFill for treating acne scars
Pearl Grimes, Vitiligo and Pigmentation Institute, Los Angeles, CA, United States;
Stacy Smith, Private Practice, Cardiff, CA, United States
Background: Dermal fillers have been used off-label for the treatment of acne scars.
At the present time, there are no FDA-approved filler products for this indication. A
dermal filler implant composed of nonresorbable polymethylmethacrylate (PMMA)
microspheres suspended in a bovine collagen carrier gel has been developed and
FDA approved for treatment of nasolabial folds. To demonstrate the safety and
efficacy of this product in atrophic acne scarring, a study was conducted.
Methods: This was a prospective, randomized, double-blind, controlled, multicenter
cross-over study. Subjects were required to have at least 4 acne scars in the facial area
that met the following criteria: soft-contoured, rolling scars that were distensible
and moderate to severe (3 or 4) on a validated 4-point (1-4) acne scar rating scale
(ASRS). Subjects were randomized to receive either PMMA-collagen or control
injections of saline. Both a treating investigator and blinded investigator performed
live assessments, and subjects performed self-assessments. Subjects were deemed
responders if 50% or more of their scars improved by at least 2 grades on the ASRS.
Visits were scheduled every 2 weeks for the first month, then at month 3 and 6. At
month 6, subjects who had received control injections could be treated with PMMAcollagen. All subjects were followed for an additional 6 months after crossover.
Results: One hundred forty-seven subjects were enrolled and underwent treatment.
At the 6-month timepoint, 64.4% of PMMA-treated subjects were graded as
responders compared to 32.6% of the control subjects (P ¼ .0005). The rate and
severity of adverse events were typical for an injectable and were similar between
active and control subjects. No serious adverse events caused by the PMMA product
were noted during the blinded period. Crossover subjects subsequently treated with
PMMA-collagen so showed similar response levels. PMMA subjects followed for 12
months continued to show an excellent safety profile.
Discussion: This large study successfully demonstrates the effectiveness and safety
of PMMA in atrophic acne scars. Patients can obtain improvement in their scars with
minimal risk or downtime and benefit. The response persisted through 12 months
consistent with PMMA permanence. The safety profile of initial injections is similar
to that seen with other fillers. Very few adverse events are noted in the 12 months
after the initial injection period.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P7573
P8190
Subject-reported outcomes over 2 years with a volumizing hyaluronic acid
filler for midface volume deficit
Sue Ellen Cox, MD, University of North Carolina and Aesthetic Solutions, Chapel
Hill, NC, United States; Deepali Paradkar, PhD, Allergan, Inc, Irvine, CA, United
States; Diane Murphy, MBA, Allergan, Inc, Irvine, CA, United States; Julius Few,
MD, University of Chicago, Chicago, IL, United States
Methods: Fifteen North American investigational sites used a volumizing HA filler to
treat 235 subjects who had moderate to severe age-related midface volume deficit. At
quarterly follow-up visits for 2 years the subjects rated the treatment outcomes on
the Global Aesthetic Improvement Scale, overall satisfaction with facial appearance,
satisfaction with midfacial regions, look and feel of the midface, achievement of
treatment goal, and self-perception of age. Subjects also completed 30-day diaries to
record common treatment site responses.
Results: At 6 months after treatment, 93% of subjects rated their cheek volume as
improved or much improved on the Global Aesthetic Improvement Scale, and a
majority of subjects still felt that way at 2 years. Improvement in satisfaction with
facial appearance over baseline was noted by 90% of subjects at 6 months and 76% of
subjects at 2 years. Satisfaction with the outer and lower cheek areas improved from
23% at baseline to 86% at 6 months, and cheek bone projection improved from 30%
to 85%. At baseline, a majority of subjects rated their cheeks as making them look
tired, sad, unattractive, and older than they wanted to look. Statistically significant
improvements were noted for all of these categories at 6 months. Two-thirds of
subjects rated their treatment goals as having been met at 6 months, and almost half
agreed that the goals were still attained at 2 years. At every timepoint through 2
years, a majority of subjects perceived themselves as looking younger than they did
at baseline. On average, subjects reported looking 5 years younger at 6 months and 3
years younger at 2 years. The most common treatment site responses reported were
tenderness, swelling, firmness, and lumps/bumps, most of which were mild to
moderate in severity and lasted 2 weeks or less.
The efficacy, safety, and subject satisfaction of pain management of a selfocclusive topical anesthetic cream during and after filler injections for the
correction of nasolabial folds
Kenneth R Beer, MD, PA, General, Cosmetic, and Surgical Dermatology, West
Palm Beach, FL, United States; Mary Lupo, MD, Lupo Center for Aesthetic and
General Dermatology, New Orleans, LA, United States
In an effort to provide more efficacious topical anesthesia, some physicians have
used compounded topical anesthetics that lack standardization to make patients
more comfortable during and after filler injections. Efficacy, safety, and subject
satisfaction were assessed in this multicenter, open-label, randomized, split-face
study. An FDA approved anesthetic cream of lidocaine and tetracaine 7%/7% (LT
cream) was compared to a compounded topical anesthetic (BLT ointment:
benzocaine 20%, lidocaine 6%, and tetracaine 4%) during and after hyaluronic
acid filler injections for the correction of nasolabial folds (NLF). This study included
51 subjects who received concurrent 30-minute applications of LT cream and BLT
ointment to opposite sides of the subjects face before injection. This study group
comprised primarily women (98%) who were white (98%) with Fitzpatrick skin
types III to IV (84%) and a median age of 49 years. There were no significant
differences in subject-reported visual analog scale (VAS) scores or investigator
assessment of subject pain at any time point. However, a significant difference was
reported by independent observers who believed that most subjects experienced
less pain with LT cream than with BLT ointment at the first needle stick (P ¼.045),
but not at any other time point. Most subjects reported that the level of pain
experienced at the first needle stick was minimal or mild for the LT cream and BLT
ointment groups (74% vs 76%, respectively). Likewise, most investigators (86% for
both treatments) reported adequate anesthesia with both topical anesthetics. There
was a significant difference in the distribution of erythema severity and edema
severity between the LT cream and BLT ointment groups (P ¼ .003). During the
study, 3 subjects reported treatment emergent AEs (implant site bruising) that were
mild in severity and definitely unrelated to the topical anesthetics. LT cream is an
effective and safe alternative to use with filler injections for the correction of
nasolabial folds.
Conclusion: The volumizing HA filler for age-related midface volume deficit is
effective and well-tolerated from the subject perspective, with results lasting up to 2
years.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
Objective: To examine the effectiveness of a volumizing hyaluronic acid (HA) filler
(Allergan, Inc) from the subject perspective.
Supported by Allergan, Inc.
P8523
P8317
Background: One of the desired outcomes in dermatologic surgeries and other
invasive procedures is to have the resulting scar be as aesthetically pleasing as
possible. Although a scar can be viewed as unsightly, the primary purpose of a scar is
to reduce the likelihood of infection of the damaged area. There are many
commercially available methods for reducing the appearance of scars. One of the
most common ingredients in these treatments is onion extract (Allium cepa).
Studies have established antiinflammatory properties of onion extracts and other
onion-based compounds, the 2 ingredients in onion extract being cepanes and
thiosulfinates. Patients may prefer these onion extractebased products because of
their ‘‘botanical’’ ingredients, ample availability, and low cost compared to other scar
reducing products.
Objective: To present data from a randomized, controlled, 8 week study of a new
onion extract gel test product referred to as PM onion extract gel in reducing the
appearance of scars.
Methods: At baseline, 44 males and/or female participants were evaluated and
enrolled into the study. PM onion extract gel was applied once daily in the evenings.
Each participant was required to have 2 scars in the same evaluation area (different
scar types were admitted). The wounds were documented by high resolution
scientifically matched photography and evaluated by an expert grader at baseline
and at weeks 2, 4, and 8. Participants were also required to complete a subjective
questionnaire at the mentioned time points.
Results: The investigator assessments showed that the PM onion extract gel
significantly improved the appearance of scars over an 8-week period. The majority
of the responses to the subject questionnaire were consistent with the conclusion
reached by the expert visual grader and the photogrammetry, in that scars were less
visible than before they started treatment.
Conclusions: The new proprietary PM onion extract gel significantly improves the
appearance of various types of scars after 8 weeks of once-daily evening application.
Twice daily application of a topical formulation containing caffeine,
forskolin, and the TPM delivery system was able to significantly reduce
the visible appearance of cellulite
Paul Gavin, PhD, Phosphagenics Ltd, Clayton, Australia; Biljana Nikolovski, PhD,
Phosphagenics Ltd, Clayton, Australia; Giacinto Gaetano, Phosphagenics Ltd,
Clayton, Australia; Mahmoud El-Tamimy, PhD, Phosphagenics Ltd, Clayton,
Australia; Roksan Libinaki, PhD, Phosphagenics Ltd, Clayton, Australia
Research and development has shown that a mixture of tocopheryl phosphate (TP)
and di tocopheryl phosphate (T2P) was able increase the absorption of molecules
into or through the skin after topical application. This mixture has formed the basis
of a novel delivery technology called TPM. TPM was formulated with the lypolytic
actives, caffeine and forskolin, to develop a topical formulation able to reduce the
visible appearance of cellulite. Thirty women with visible cellulite on both thighs
were recruited for the study. The test product was applied twice per day (morning
and night) to the affected area of a single thigh over a 56-day period. The opposite
thigh was left as an untreated control. Elasticity and viscoelastic properties of the
skin were measured as a function of flexibility and firmness using a cutometer.
Hydration level of the skin surface was evaluated instrumentally using a
Corneometer. The efficacy and tolerance were evaluated using panelist selfassessment via questionnaire responses and measurements of upper thigh circumferences were also collected. A subset of 5 subjects were randomly chosen for
additional photogrammetric investigation, where image analysis software was used
to quantify changes in cellulite condition observed in the scientifically matched
photographs. Analysis of the chosen parameters was conducted before the initial
application (at baseline) and again after 14, 28, 42, and 56 days of use. Cutometer
readings demonstrated that the test material increased the average the skin elasticity
by 10.36% and hydration by 52.63% after 56 days of treatment when compared to
the untreated leg, Both increases were statistically significant. Image analysis
software demonstrated that the test product progressively reduced the visual
appearance of the cellulite. At the end of the study, the test product significantly
reduced the visible appearance of cellulate by an average of 57.40% with maximum
of 72.12%. The test product also significantly reduced the average thigh circumference by an average of 0.92% (0.36 cm) after 8 weeks of use. Subjective questionnaire
responses corroborated instrumental data. The majority of test panelists responded
positively to perceived benefits with the test product demonstrating improvement
in skin’s firmness, tightness, and reduction in skin’s looseness and bagginess after 56
days of use. At the study completion, a majority of test panelists perceived the test
material to be an effective anticellulite product.
Supported by Merz Pharmaceuticals, LLC.
Supported by Phosphagenics Ltd.
The ability of a new proprietary onion extract gel to reduce the
appearance of scars: A randomized, controlled study
Stefan Plaum, MD, Merz Pharmaceuticals, LLC, Greensboro, NC, United States;
Alan Fleischer, MD, Merz Pharmaceuticals, LLC, Greensboro, NC, United States;
Amit Verma, PhD, MPH, Merz Pharmaceuticals, LLC, Greensboro, NC, United
States; Babajide Olayinka, MS, Merz Pharmaceuticals, LLC, Greensboro, NC,
United States; Bhushan Hardas, MD, MBA, Merz Pharmaceuticals, LLC,
Greensboro, NC, United States
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB21
P8063
P7534
Volumizing and moldability characteristics of crosslinked hyaluronic acid
fillers
Garrett Shumate, Allergan, Inc, Irvine, CA, United States; Darin J. Messina, PhD,
Allergan, Inc, Irvine, CA, United States; Dennis Van Epps, PhD, Allergan, Inc,
Irvine, CA, United States; Sumit Paliwal, PhD, Allergan, Inc, Irvine, CA, United
States; Vic Narurkar, MD, Bay Area Laser Institute, San Francisco, CA, United
States
Purpose: To study the comparative lift capacity, moldability profile, and tissue
integration of volumizing crosslinked hyaluronic acids in a novel animal model.
Antiaging bionic and polyhydroxy acids reduce nonenzymatic protein
glycation and skin sallowness
Barbara A. Green, MS, NeoStrata Company, Inc, Princeton, NJ, United States;
Brenda L. Edison, NeoStrata Company, Inc, Princeton, NJ, United States; Krys
Bojanowski, PhD, Sunny BioDiscovery, Inc, Santa Paula, CA, United States; Ronni
L. Weinkauf, PhD, NeoStrata Company, Inc, Princeton, NJ, United States
Design: Sprague Dawley rats, 3 months in age, were injected subcutaneously with
125 microliters of 3 different crosslinked hyaluronic acid fillers (VYC-20L [20
mg/mL]; HYC-24L+ [24 mg/mL]; PERL [20 mg/mL]) and followed for 12 weeks
postinjection. The mean height of the injection bolus for each filler was measured
using quantitative 3D imaging to evaluate tissue lift capacity. Additional imaging
experiments measuring the change in the height of the injection bolus after
standardized mechanical compression were performed to evaluate the moldability
characteristics of these fillers over 9 days. Histology was performed to correlate the
study observations.
Summary: After a small but rapid decrease in bolus height, VYC-20L provided
substantial tissue lift, which resisted flattening over 12 weeks. It was also readily
moldable immediately after injection to achieve desired contour yet set into tissue
quickly and resisted deformation thereafter compared to the other studied fillers.
Histologic evaluation showed rapid integration with the subcutaneous tissue
compared to the other fillers examined.
Conclusion: In animal studies, VYC-20L exhibited sustained lift capacity, a favorable
moldability profile with faster setting time into the tissue, and rapid tissue
integration. This is suggestive of a favorable clinical profile for VYC-20L with
respect to its ability to contour and volumize areas.
Supported by Allergan.
Skin aging is a multimechanistic process that includes protein glycation. Protein
glycation is the nonenzymatic joining of a sugar with an amino group found on
proteins, such as collagen, forming advanced glycation end-products (AGEs). AGEs
accumulate in skin naturally with age and are increased in various disease states
including diabetes. They lead to a gradual cross-linking of collagen which results in
reduced elasticity. This altered collagen is also less susceptible to normal catabolism
and thus accumulates over time. AGEs are formed by the Maillard reaction which
causes enzymatic browning. In skin, AGEs can be yellow in color and contribute to a
sallow appearance of skin. The Maillard reaction is accelerated by oxidative stress
and the oxidative reaction products are elevated in aging skin. Anti-glycation is
considered an important antiaging approach in the maintenance of healthy skin.
Compounds that inhibit nonenzymatic glycation may function in several ways,
including as an antioxidant and/or chelator of oxidation promoting metals. The
bionic acids, including lactobionic and maltobionic acids, and the polyhydroxy acid,
gluconolactone, have previously been shown to provide numerous antiaging
benefits to skin. An in vitro study was conducted with these ingredients and
showed a dose-dependent inhibitory effect on nonenzymatic glycation that was
statistically significant (P \.05) compared to water control and similar in efficacy to
the positive control aminoguanidine. In vivo studies were conducted with up to 10%
concentrations of these ingredients in topical cream formulations applied twice
daily to the face. Visual assessment of sallowness over 12 weeks showed a
statistically significant improvement up to 36% (P \ .05). These results show a
new mechanism by which these 3 ingredients provide antiaging benefits. The data
demonstrate that lactobionic acid, maltobionic acid and gluconolactone are
effective in reducing AGEs, and improving sallowness and tone. Glycation inhibitors
may be useful to help preserve skin’s own natural collagen and enhance skin
elasticity and resiliency.
Commercial support: None identified.
AGING/GERIATRICS
P8414
The need for efficacious topical formulations that achieve pigment lightening has
created dermatologic challenges with the recent FDA concerns regarding the safety
of hydroquinone and EU concerns regarding the safety of kojic acid. This research
examined the topical efficacy of lignin peroxidase, an enzyme derived from the tree
fungus Phanerochaete chrysosporium, in pigment lightening. Lignin peroxidase
breaks down cell walls in decaying plant material, but also breaks down melanin in
the presence of veratryl alcohol and a pH\4.5. Sixty female subjects age 18-65 years
with Fitzpatrick skin types I-IV and mild to moderate symmetrical facial dyspigmentation, as defined as a MASI score between 1-3, were enrolled for 12 weeks in 2
cohorts. Cohort 1 with 30 subjects applied the lignin peroxidase lotion (LPL) to one
randomized side of the face and nothing to the opposite side. Cohort 2 of another 30
subjects applied the LPL to one randomized side of the face and generic 4%
hydroquinone (HQ) to the opposite side. This allowed subjects to serve as their own
control while separately comparing no treatment and HQ efficacy to the LPL. All
study products were applied twice daily and all subjects used consistent study
provided skin care products to the entire face. Dermatologist investigator and
subject assessments were obtained on a 5-point ordinal scale. In addition,
photography and target spot dermospectrophotometer (DS) measurements were
obtained. Fifty-nine of 60 subjects completed the 12-week study (2, 4, 8, and 12
week evaluation time points). No adverse events or adverse experiences occurred in
either group. In cohort 1, improved skin texture (P \.001), roughness (P \.001),
and overall appearance (P ¼.002) was noted at week 2 with the LPL as compared to
the no treatment side. By week 12, there was a decrease in spot size with the LPL as
compared to no treatment (P ¼.014). This was confirmed by a statistically significant
reduction in melanin scores with the DS on the LPL treated side at weeks 4, 8, and 12
(P ¼ .003) and a similar reduction in MASI score. Cohort 2 demonstrated parity
between the LPL and HQ in terms of DS and MASI score at week 12, but the LPL was
statistically superior in terms of skin texture and roughness at all time point. This
study demonstrated that LPL might be an OTC skin lightening preparation with
efficacy parity to HQ.
Antiaging treatment of periorbital and perioral fine lines and wrinkles
with a home-use 1440-nm laser
Stacy Hawkins, PhD, Unilever R&D, Trumbull, CT, United States; Gideon Smith,
MD, Dermatology Associates, Boston, MA, United States; James Boll, Cynosure,
Inc, Westford, MA, United States; Mary Stoll, RN, Cynosure, Inc, Westford, MA,
United States; Paul Cardarelli, Cynosure, Inc, Westford, MA, United States
Previously, nonablative laser treatment of periorbital and perioral rhytids could only
be performed in an office setting by trained medical professionals. The efficacy of an
FDA-cleared nonablative 1440-nm laser device designed for consumer home-use
treatment of periorbital and perioral rhytids was evaluated in a 22-week study under
nurse treatment conditions. Fifty-eight healthy female panelists, ages 40-70 years,
Fitzpatrick skin type I-IV, provided informed consent to participate in this evaluatorblinded IRB-approved study. Panelists were treated on periorbital and perioral sites
by nurses, 53/wk over the course of 12 weeks. Initially, the high setting of the
device was used for all treatments. 24-hour posttreatment, the treating nurses
evaluated clinical irritation (if any), and would move to the low setting or skip a
treatment if warranted. After the initial 12 week period a randomly selected subset
(N ¼ 20) continued on a 23/wk maintenance regimen for a further 4 weeks. All
panelists were evaluated in-person by an independent dermatologist using the
validated 0-9 Fitzpatrick Wrinkle Scale (FWS, ½ point increments allowed), and
separate evaluation was performed with digital photos, 3D evaluation of texture
(Primos), and panelist surveys at baseline and after 4, 8, 12, and 16 (maintenance)
weeks of treatment as well as a 6 weeks follow up after the last treatment (no
treatment regression). Treatments were well tolerated, with 38 panelists receiving
the majority of treatments using the high setting of the device and good protocol
compliance to the total number of treatments. The most common side effect was
mild erythema, with an occurrence rate of only 0.57%. Independent blinded
dermatologist assessment of photodamage showed significant reduction to periorbital lines and wrinkles by 2 weeks of treatment, and by week 12 for the perioral
site. After 12 weeks of treatment 93.1% and 60.3% of subjects showed improvement
in the periorbital and perioral sites, respectively (mean FWS reduction P \.05 of
1.22 6 0.09, 0.34 6 0.08). In the maintenance group, these benefits were
maintained after 23/wk treatment, and similarly efficacy was maintained in both
maintenance and nonmaintenance groups in follow up evaluations 6 weeks after the
last treatment. Panelist surveys confirmed the benefits to lines and wrinkles
observed clinically. The results of this study showed good tolerance and efficacy
for treating periorbital and perioral wrinkles with the 1440nm home-use device.
Supported 100% by a research grant from Syneron.
Sponsored 100% by Unilever.
P7900
A split face evaluation of a lignan peroxidase pigment lightening agent
compared to no treatment and 4% hydroquinone
Zoe Draelos, MD, High Point, NC, United States
AB22
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8410
P7695
Clinical benefits of a skin care regimen with PPARs, retinol, and AHAs in a
double-blind, split-face application, vehicle-controlled study
Stacy Hawkins, PhD, Unilever R&D, Trumbull, CT, United States; Ana MartinHerranz, PhD, Unilever R&D, Madrid, Spain; Helen Meldrum, PhD, Unilever R&D,
Trumbull, CT, United States
Clinical evaluation of the efficacy and tolerance of a body gel in
conjunction with laser hair removal on the legs
Amanda Dahl, L’Oreal Research and Innovation, Clark, NJ, United States;
Christian Oresajo, L.Oreal Research and Innovation, Clark, NJ, United States;
Margarita Yatskayer, L’Oreal Research and Innovation, Clark, NJ, United States;
Nannan Chen, L’Oreal Research and Innovation, Clark, NJ, United States; Susana
Raab, L’Oreal Research and Innovation, Clark, NJ, United States; Yevgeniy Krol,
Skinceuticals Inc, New York, NY, United States
Introduction: Dry skin is most common in certain areas of the body including the
lower legs and arms. It happens more often in the winter months with the
combination of cold air outside and heated air inside, causing low humidity. This
study was designed to test the efficacy and tolerance of a body gel containing
Hydrovance, HEPES, Hyaluronic Acid and vitamin B3 used on the legs/knees and
arms/elbows in a panel of multiethnic females.
Photoaged skin is the manifestation of extrinsic damage from ultraviolet radiation
and environmental stressors superimposed on the intrinsic aging process. Cosmetic
peroxisome proliferator-activated receptor (PPAR) lipids, for example conjugated
linoleic acid (CLA), and antiaging ingredients, such as retinol and alpha hydroxyl
acids (AHAs), have been shown to significantly improve the photoaged appearance
of skin. The objective of this research was to demonstrate improvement to
photodamaged facial skin using a facial regimen of topical products with effective
antiaging ingredients (eg, CLA, Retinol, AHAs, Niacinamide, Survixyl). Forty white
female panelists (ages 40 to 70) with a moderate to severe degree of photodamage
were enrolled into a 12-week, randomized, double-blind, split-face application study.
Panelists applied the test products twice daily over the course of the treatment. The
test products included a day cream (SPF 15) with a serum containing a combination
of CLA, retinol, and glycolic acid, which was applied to one side of the face, and 2
vehicle moisturizers which were applied to the other side of the face. Expert visual
assessment of photodamage was assessed and digital photos were obtained at
baseline and at weeks 8 and 12. Results showed that the regimen of the day cream
and serum provided a significant reduction in the appearance of coarse wrinkles
from baseline and compared to vehicle control at weeks 8 and 12. Consumer studies
were conducted in parallel with full formulation facial products containing the same
CLA active level: a day cream (SPF 15 containing CLA, Niacinamide, Survixyl), and an
eye cream (containing CLA, caffeine and Survixyl). Results confirmed consumer
perceivable benefits to photodamaged skin appearance (eg, reduction of lines and
wrinkles appearance, more even skin tone). In separate clinical tests, all products
showed improved hydration (capacitance) after a single application, with low
irritation under patch. These results demonstrate the facial regimen products
provide antiaging benefits to the appearance of photodamage, without the irritation
normally associated with effective antiaging treatment options.
Sponsored 100% by Unilever R&D.
Methods: This 8-week clinical study included 53 females aged 30-53 with the
majority of the panel having dry to very dry skin. Subjects were instructed to apply
the test product once daily in the morning after showering. Subjects were evaluated
for skin dryness (flaking), smoothness, skin tone, radiance, texture, softness,
suppleness and overall appearance at baseline, week 4 and week 8. In addition,
subjects were evaluated for objective and subjective tolerance. Subject selfassessment questionnaires, noninvasive bioinstrumental assessments of hydration
and transepidermal water loss (TEWL), D-squame samples and digital photography
were also included in the study.
Result: The results from this clinical study showed that treatment with the body gel
produced a statistically significant improvement in clinical grading scores for all
efficacy parameters (assessed on the lower legs, knees, volar forearms, and elbows)
including skin dryness (flaking), smoothness, skin tone, radiance, texture, softness,
suppleness and overall appearance at week 4 and week 8 when compared to
baseline scores. Noninvasive bioinstrumental evaluation indicated that this treatment produced a statistically significant improvement in hydration and TEWL after 8
weeks of product use. In addition, a significant improvement was observed with Dsquame samples in the decrease of the values for coarse flakes on the lower legs after
4 weeks of use. Questionnaire analyses indicate that the treatment was wellperceived by subjects.
Sponsored 100% by L’Oreal.
P8587
P7693
Clinical efficacy and tolerance of a novel antioxidant night treatment
containing Resveratrol, Baicalin, and vitamin E on women with mild to
moderate photodamaged facial skin
Margarita Yatskayer, L’Oreal Research and Innovation, Clark, NJ, United States;
Amanda Dahl, L’Oreal Research and Innovation, Clark, NJ, United States;
Christian Oresajo, L’Oreal Research and Innovation, Clark, NJ, United States;
Nannan Chen, L’Oreal Researc and Innovation, Clark, NJ, United States; Susana
Raab, L’Oreal Research and Development, Clark, NJ, United States; Theresa
Chen, L’Oreal Research and Innovation, Clark, NJ, United States; Yevgeniy Krol,
Skinceuticals Inc, New York, NY, United States
Purpose of study: Topical products containing antioxidants have been demonstrated
to be effective in protecting the skin against the damaging effects of free radicals and
oxidative stress produced by normal cellular metabolism or photodamage. The
purpose of this study was to evaluate the effectiveness and tolerance of an
antioxidant composition containing Resveratrol, Baicalin, and vitamin E tested in
subjects with clinically determined mild to moderate photodamaged facial skin.
Method: Fifty (50) female subjects between the ages of 40 and 60 were enrolled in a
12-week single center, controlled clinical study. Female volunteers applied the
topical product to their face, neck and chest areas at night for the duration of the
study. Evaluations were performed at baseline, 4 weeks, 8 weeks, and 12 weeks after
test article use. Assessments included subjective and objective tolerance evaluations
using a 4-point scale, expert clinical grading of facial skin attributes including fine
lines and wrinkles in the periorbital area, firmness/elasticity, skin laxity, density, skin
radiance, skin tone evenness, skin roughness, hyperpigmentation, and the overall
skin appearance using a 10 point scale. Subject self-assessment questionnaires,
noninvasive bioinstrumentation to assess skin density, and digital photography were
also included in the study. 10 (10) subjects were selected randomly to have 2-mm
punch biopsies collected from the face area (baseline and week 12) and buttock area
(baseline only). PCR analysis was carried out on the biopsies for COL1A1, GSS, HO-1,
PRKAA1and SOD1.
Results: Statistically significant improvements were observed in all facial skin
attributes at all time points when compared to baseline. Bioinstrumentation
measurements showed a statistically significant improvement in skin density.
Analysis of biopsy samples showed improvements in expression of COL1A1 and
HO-1. Global tolerance evaluations showed the antioxidant night treatment to be
well tolerated by the study panel.
Sponsored 100% by L’Oreal.
Clinical studies demonstrate the capacity of a novel emulsion to improve
facial skin features associated with dryness and photodamage
Michael Traudt, PhD, Revlon Research Center, Edison, NJ, United States; Lelani
Lagman, Revlon Research Center, Edison, NJ, United States; Marilyn Callahan,
Revlon Research Center, Edison, NJ, United States; Sarah Yuro, Revlon Research
Center, Edison, NJ, United States; Stanley Levy, MD, Revlon Research Center,
Edison, NJ, United States; Susan Feng, PhD, Revlon Research Center, Edison, NJ,
United States; Victoria Tu, PhD, Revlon Research Center, Edison, NJ, United
States
Background: Emulsions are effective vehicles for delivering compounds that
mitigate the common signs of photodamage. It is technically challenging to provide
these benefits from a foundation make-up containing complex polymers, clays, and
pigments. We developed a silicone-based foundation containing emollients and
humectants designed to deliver the benefits of a ‘‘skin lipid replacement’’ complex
and a proprietary compound (REV174) to mitigate the common signs of
photodamage.
Objective: To demonstrate the potential for treatment benefits from a foundation
make-up.
Methods: An in vitro bioassay was conducted to evaluate the potential of REV 174 to
increase skin collagen synthesis in human dermal cell lines. Normal human dermal
fibroblasts (NHDF) and normal human epidermal keratinocytes (NHEK) were
treated with a series of noncytotoxic doses of REV174. The expression of collagen
I, III, and IV were quantified using in situ immmunolabeling. A single-blind monadic
designed study was undertaken under the supervision of a board-certified
dermatologist. Fifty-eight females ages 35 to 60 with mild to moderate photodamage
were instructed to use the test product daily for 12 weeks without additional
moisturizers. Subjects were assessed at 1, 4, 8, and 12 weeks by an expert grader
using a 10-point modified Griffiths’ scale. Product tolerance was also assessed and
self-perception questionnaires were submitted at each visit. In an additional study
with the same formula skin hydration was measured over 8 hours using the Moisture
Meter SC Compact (Delfon Technologies Ltd).
Results: In the in vitro study, REV 174 increased the neosynthesis of collagen I and II
by NHDF but not of collagen IV by NHEK. Expert grading scores demonstrated that
the test product significantly (P \.05) improved the appearance of skin clarity, fine
lines, tactile and visual smoothness, evenness of skin tone, and overall photodamage. The product was well tolerated. Questionnaires revealed self-perceived
benefits consistent with objective grading and adequate daily makeup coverage.
Improvement in skin hydration was demonstrated instrumentally.
Conclusion: A facial foundation can be formulated to improve photodamage, and
skin hydration despite the use of additional ingredients not found in standard
treatment emulsions. These results suggest that the test product could serve as a
stand alone daytime moisturizer and/or ‘‘wrinkle cream’’ or alternatively be used to
augment a daily skin care regimen.
Sponsored 100% by Revlon.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB23
P8184
P7964
Comparison of improvements in facial skin appearance among women in
2 different age groups after cosmetic moisturizer treatments
Uma Santhanam, PhD, Global R&D, Avon Products, Inc, Suffern, NY, United
States; Dawn Paradie, Global R&D, Avon Products, Inc, Suffern, NY, United
States; John Lyga, PhD, Global R&D, Avon Products, Inc, Suffern, NY, United
States
Evaluation of the efficacy of a facial lotion in females with stressful
lifestyles
Maria Vitale, L’Oreal Research & Innovation, Clark, NJ, United States; Christian
Oresajo, L’Oreal Research & Innovation, Clark, NJ, United States; Margarita
Yatskayer, L’Oreal Research & Innovation, Clark, NJ, United States; Valerie
Robert, L’Oreal Research & Innovation, Clark, NJ, United States
Background: With the aging of the baby boomer generation, the desire for cosmetic
products to improve the appearance of facial skin continues to expand into older
populations of women. As a result, there is a need to understand how cosmetic
products impact the appearance of facial skin in different groups of aged
populations. The goal of this study was to clinically evaluate the ability of 2 different
cosmetic skin treatment products to elicit an improvement in skin attributes
associated with photodamaged skin n white women of 2 different age groups: 30-59
and 60-75.
Introduction: Stressful situations have been shown to induce many physiologic
responses, including variations in facial skin conductance, redness, and skin
temperature. There is a need for a topical product that reduces the visible signs of
stress, which include redness, skin fatigue, and dryness. The purpose of the study
was to evaluate a facial lotion containing Rosa Gallica Extract, Chamomilla extract
and Mannose in females who live stressful lifestyles.
Method: This clinical study included 50 female subjects aged 18 and 45 who
professed and agreed that their stressful lifestyles have resulted in mild to moderate
dryness, dullness, skin fatigues, and redness. Evaluations were done at baseline,
postapplication, and challenge with interview, and after 1 day, 1 week, and 4 weeks
of product application. Assessment of skin redness and transepidermal water loss
(TEWL) were done on both sides of the face before product application and after
interview challenge. Product was applied to a randomized side of the face, the other
side left untreated serving as a control. In order to trigger a stressful situation
subjects were subjected to an interview which lasted 5 minutes. Subjects began fullface application of the facial lotion, twice daily, on day 1. Evaluations were
performed by an expert grader for long-term efficacy and included grading of
objective and subjective tolerance and clinical efficacy. TEWL, subject selfassessment questionnaires, and digital photography were also included in the study.
Result: The results showed that immediately after the stressful interview an increase
in skin redness was observed on both the treated and untreated side of the face.
However, there was no significant difference between the 2 sides of the face. There
was a significant improvement in skin dryness, softness, smoothness, radiance,
blotchiness, fatigue, overall facial lines, and skin quality after 1 week and confirmed
after 4 weeks. There was an improvement in skin redness after 4 weeks of product
use. There were no significant differences in TEWL values after 4 weeks of product
use when compared to baseline indicating the product is mild and does not cause
skin barrier damage. The product was well tolerated by the subjects after 4 weeks of
use.
Methods: Two independent randomized, double-blind 12-week facial studies were
conducted in the US enrolling women from 2 different age groups, 30-59 and 60-75,
with mild to moderate signs of skin aging (including fine and coarse wrinkling, and
discrete andmottled pigmentation and overall photodamage). The women in each
age group applied 2 different moisturizer formulations once daily: moisturizer
formulation 1 containing a mixture of active synthetics and botanical extracts or
formulation 2, with the above combination of actives plus glycolic acid and
thiodipropionic acid, an antioxidant. Grading of subjects for visual improvement
in various attributes on a 0-9 scale was performed by a board-certified dermatologist
at week 1, 2, 4, 8, and 12. Responses were compared among the 2 age groups.
Results: Women in both the younger and the older age groups demonstrated
significant improvement from baseline in pigmentation, wrinkles and overall
photodamage in response to application of moisturizer formulations for 12 weeks.
With the use of formulation 1, it was observed that the magnitude of improvement in
most of the individual attributes in the younger group was significantly higher
relative to the older group. With formula 2, the wrinkling and photodamage
improvements were significantly higher in the younger group but similar improvements in pigmentation was seen in both the older and younger groups. The lower
magnitude of response for certain attributes in older women may be related to the
fact that the respective baseline scores were higher, as expected in the older
population. The above studies suggest that, in general, improvements in age-related
appearance of skin following treatment with cosmetic moisturizers can be elicited
regardless of age.
Sponsored 100% by L’Oreal.
Commercial support: None identified.
P8138
Efficacy comparison of a cosmetic exfoliation system with professional
microdermabrasion
Joseph Kaczvinsky, PhD, The Procter and Gamble Company, Cincinnati, OH,
United States; Catherine Mack, The Procter and Gamble Company, Cincinnati,
OH, United States; James Li, MS, The Procter and Gamble Company, Cincinnati,
OH, United States; Kali Ghazali, Vitiligo and Pigmentation Institute of Southern
California, Los Angeles, CA, United States; Michael Marmor, The Procter and
Gamble Company, Cincinnati, OH, United States; Pearl Grimes, MD, The Vitiligo
and Pigmentation Institute of Southern California, Los Angeles, CA, United States
Objective: The primary objective of this study was to compare the effectiveness of a
cosmetic microdermabrasion (MDA) system versus a leading professional MDA
treatment for exfoliation. Secondary objectives compared the 2 systems’ effects on
skin barrier, hydration, and visual assessments of skin attributes.
P8366
Results: The cosmetic MDA system produced significantly higher exfoliation than
NT at day 7 pre- and posttreatment (P \.001). Furthermore, equivalent exfoliation
was seen from each MDA treatment at both day 7 pretreatment and day 7
posttreatment. After 7 and 14 days, the physician’s evaluations showed that there
a noticeable improvement in the subjects’ skin texture and pores for both
treatments and no significant difference in response between the MDA treatments.
Seventy percent of subjects noticed improvements with both MDA systems. The
cosmetic MDA system significantly prevented the loss of skin hydration compared to
the professionally administered MDA treatment 7 days posttreatment. Barrier was
not disrupted by either treatment and both were well tolerated throughout the
course of the study.
Conclusion: Used as intended, the cosmetic MDA system exfoliated as effectively as a
professional MDA treatment and produced comparable or better improvements in
hydration and in the appearance of skin texture and pores.
Immunohistologic analysis of biopsy specimens from a double-blind,
vehicle controlled, 1-year clinical study on 0.1% stabilized retinol as an
antiaging technology
Samantha Tucker Samaras, PhD, Johnson & Johnson Consumer Companies, Inc,
Skillman, NJ, United States; Jared Fantasia, MS, Johnson & Johnson Consumer
Companies, Inc, Skillman, NJ, United States; Jipsha Thakrar, Johnson & Johnson
Consumer Companies, Inc, Skillman, NJ, United States; Manpreet Randhawa,
ScD, Johnson & Johnson Consumer Companies, Inc, Skillman, NJ, United States
Many new antiaging technologies have demonstrated clinical benefits appropriate
for aging patients who visit a dermatology practice seeking visible improvements.
Many are expecting immediate results, but scientists and practicing clinicians
recognize that greater improvement can be attained over longer time periods. Many
traditional antiaging clinical studies have included 1-, 2-, and 3-month time points.
However, additional benefits can expect to be seen with longer usage. This clinical
investigation comprises a histologic assessment of biopsy specimens taken from a
double-blind, vehicle-controlled, 1-year clinical study on 0.1% stabilized retinol
formulation. All patients were females between 40 and 55 years with moderately
photodamaged facial skin representing Fitzpatrick skin types I-III. The antiaging
technology was assessed versus its vehicle throughout the 1 year of daily facial
product usage with biopsy specimens taken at baseline, 6 months, and 52 weeks of
the study. Immunohistochemical assessments were performed to investigate the
effects on epidermal proliferation and extracellular matrix production. KI-67, a
cellular marker of proliferation was increased in the retinol-treated biopsy
specimens for both the 6- and 12-month groups compared to vehicle, and the 12month group had increased number of subjects stained positive for Ki-67 compared
to the 6-month group, indicating that continued use of the retinol formulation
resulted in a greater effect. ECM protein expression measured by collagen staining
and hyaluronic acid and were both increased in the retinol treated biopsies at the 6and 12-month timepoints compared to vehicle. Taken together, these histologic
findings demonstrate that use of a 0.1% stabilized retinol formulation resulted in
continued and increased efficacy over the 52-week study The publication of robust
clinical studies with antiaging cosmeceutical formulations that are tested over
longer time periods provide excellent evidence-based results that enable practicing
dermatologists to confidently recommend the most appropriate products for their
patients.
Study was 100% sponsored and funded by the Procter & Gamble Company.
Sponsored 100% by Johnson & Johnson Consumer Companies, Inc.
Methods: A randomized, double-blind, no treatment-controlled, 2-wk, split-face
facial study was conducted including 41 female subjects aged 35-65 with Fitzpatrick
skin types I-V. Following a 3-day preconditioning period, 2 small areas on each side of
the face were stained with the self-tanning ingredient dihydroxyacetone (DHA). One
of the stained areas on each side of the face was a no treatment (NT) site. Subjects
treated one side of their face (except the NT site) 2 times weekly with a cosmetic
exfoliation system consisting of a battery-operated implement with a rotating foam
head with added abrasive sodium bicarbonate crystals. The other side of the face
(except the NT site) underwent a professional MDA treatment administered in a
dermatologist’s office on day 1 and day 7. The primary exfoliation measure was color
loss in the DHA stained areas of the face at day 7 pretreatment as measured by
chromameter. Hydration and TEWL measurements were also taken and facial images
were taken for physician’s assessments of visual changes. Subject self-evaluations
were taken via questionnaire.
AB24
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8397
P8002
Improved appearance of facial hyperpigmentation with use of a cosmetic
moisturizer containing N-acetyl glucosamine and niacinamide
James Li, MS, Procter and Gamble, Cincinnati, OH, United States; Elizabeth
JewellMotz, PhD, Procter and Gamble, Cincinnati, OH, United States; Joseph
Kaczvinsky, PhD, Procter and Gamble, Cincinnati, OH, United States; Michael
Marmor, Procter and Gamble, Cincinnati, OH, United States
In vivo multiphoton microscopy evaluation of long-term effects of retinol
and retinoic acid on photodamaged skin: A 1-year randomized, doubleblind, controlled study
Emmanuelle Tancrede-Bohin, MD, L’Oreal Research and Innovation, Centre de
Recherche Bioclinique, Paris, France; Ana-Maria Pena, PhD, L’Oreal Research and
Innovation, Aulnay sous Bois, France; Nathalie Parent, L’Oreal Research and
Innovation, Centre de Recherche Bioclinique, Paris, France; Raquel Dalmaschio,
PharmD, L’Oreal Research and Innovation, Centre de Recherche Bioclinique,
Paris, France; Sebastien Brizion, L’Oreal Research and Innovation, Aulnay sous
Bois, France; Therese Baldeweck, PhD, L’Oreal Research and Innovation, Aulnay
sous Bois, France
Multiphoton microscopy (MPM) is a noninvasive skin imaging technique that can be
coupled with specific automatic 3D image processing tools for providing precise
insights on the density and organization of different skin constituents. In this study,
30 healthy female, aged 55-65 years, with photodamaged skin were selected. They
applied either Retinol (RO, Retinol 0.3%, Skinceuticals; n ¼ 15) or Retinoic acid
0.025% (RA, Retacnyl, Galderma; n ¼ 15) to the dorsal side of one forearm versus a
control product (Diprobase, Shering-Plough) to the other forearm for 1 year
(application frequency is given below). Evaluations were performed using MPM at
D0 (March), M3 (June), M6 (September) and M12 (March + 1 year). At M12,
volunteers completed a self-assessment questionnaire and biopsies were taken for
histologic analysis. Main results versus control are (P \.05 with moderate to strong
effect sizes): (1) epidermal thickening on retinoid treated areas at M3 and M12 with
RO and at M12 with RA, with an average increase by +20 m and +10 m,
respectively; (2) increase in the undulation of the dermoepidermal junction (DEJ)
with RA at M3 and RO at M12; (3) modulation of melanin content: on control side,
seasonal effect (increased melanin density) at M3 and M6 and accumulation in the
basal layers at M12 as compared to D0 were observed, whereas on retinoid treated
sites, seasonal effect was only observed at M6 and an ‘‘ad integrum’’ return was
observed at M12; (4) qualitative improvement of the skin as assessed with self
evaluation questionnaire (RO[RA). Despite an every other day application during
the first month, cutaneous reactions were noted in 14 RO-, and in 6 RA-treated
volunteers; 5 subjects decreased the number of planned applications (1RA, 4 RO), 1
released from the study at M6 (RO). RO induced a more pronounced improvement
of age-induced skin alterations than RA, together with more cutaneous irritation,
likely caused by the high concentration used; irritation was however mild, and only
1 subject released from the study. The study shows that MPM coupled with specific
3D image processing is a powerful tool for kinetic and non invasive product
evaluation. Parameters of melanin characterization allowed the effect of retinoids on
pigmentation alterations of photodamaged skin to be measured and could be used
for other skin pigmentation disorders.
Background: Topical niacinamide and N-acetyl glucosamine (NAG) each individually
inhibit epidermal pigmentation in cell culture. In small clinical studies, niacinamidecontaining and NAG-containing formulations reduced the appearance of
hyperpigmentation.
Methods: Two large independent randomized, double-blind, vehicle-controlled 8week facial studies were conducted in the United States (Cincinnati, OH) and China
(Beijing) with women 40-60 (US) and 25-55 (China) years old with moderate to
severe facial hyperpigmentation. The women applied a moisturizer containing Nacetyl glucosamine (NAG) and niacinamide daily during the day and a night cream
containing 10% glycerin at night in a full randomized study design with a moisturizer
base vehicle as control. Cheek area hyperpigmentation were measured by digital
imaging analysis of spot area at 0, 4, 6, and 8 weeks. Skin barrier function was
measured by vapometer at 0, 4, and 8 weeks.
Results: In both studies, use of the cosmetic moisturizer formulation containing
NAG and niacinamide significantly improved the appearance of cheek area hyperpigmentation as compared to vehicle. The improvement was apparent at the earliest
timepoint evaluated (4 weeks) and increased in magnitude for the duration of
product use (8 weeks) especially in the Chinese study. The magnitude of
improvement was approximately the same between the white (US) and Chinese
women. The skin barrier improvement was observed in both whites and Chinese.
Conclusions: Daily use of a cosmetic moisturizer containing N-acetyl glucosamine
(NAG) and Niacinamide improved the appearance of signs of facial skin aging such
as hyperpigmentation. A moisturizer containing NAG produced significant better
skin barrier function compared to a regular moisturizer. The finding of comparable
improvements between white (US) and Chinese women indicates that daily use of
the cosmetic moisturizer formulation containing NAG and Niacianmdie can improve
facial appearance in women of different races and geographies.
Sponsored 100% by Procter and Gamble.
Commercial support: None identified.
P8012
Improved appearance of facial wrinkles in post menopausal women with
use of a cosmetic moisturizer containing specifically prepared artichoke
extract
Lisa Mullins, Procter & Gamble, Mason, OH, United States; James Li, MS, Procter
& Gamble, Cincinnati, OH, United States; Joseph Kaczvinsky, PhD, Procter &
Gamble, Cincinnati, OH, United States; Rosemarie Osborne, PhD, Procter &
Gamble, Mason, OH, United States
P8157
Conclusion: Daily use of a cosmetic moisturizer containing a specifically prepared
artichoke extract improved the appearance of signs of facial skin aging such as fine
lines and wrinkles. The finding of faster improvements with the women age 55+
than the women age \ 48 years old indicates that daily use of the cosmetic
moisturizer formulation can improve facial appearance in women of different ages at
different speeds.
In vivo short-term effect of tetra-hydro-jasmonic acid upon the pigmentation of photodamaged skin
Emmanuelle Tancrede-Bohin, MD, Centre de Recherche Bioclinique e L’Oreal
Research & Innovation, Paris, France; Ana-Maria Pena, PhD, L’Oreal Research &
Innovation, Aulnay sous Bois, France; Julien Faugere, L’Oreal Research &
Innovation, Aulnay sous Bois, France; Luc Souverain, L’Oreal Research &
Innovation, Aulnay sous Bois, France; Nathalie Parent, Centre de Recherche
Bioclinique - L’Oreal Research & Innovation, Paris, France; Therese Baldeweck,
PhD, L’Oreal Research & Innovation, Aulnay sous Bois, France
The occlusive patch test initially developed for assessing the effects of topical
retinoids on human skin has been extended to a short term protocol for screening
antiphotoaging agents. In a previous pilot study, we showed that in vivo
multiphoton microscopy, a recent noninvasive skin imaging technique, could be
used as an evaluation tool overcoming the necessity of invasive biopsies. The
objective of this study was to evaluate the effect of tetra-hydro-jasmonic acid (TEJ), a
recently discovered antiaging product derived from jasmonic acid. Accordingly, a
randomized, double-blind, monocentre comparative study was performed involving
16 volunteers (55-65 years), with photodamaged skin. 0.2% TEJ and its vehicle alone
were applied to the dorsal side of the forearm under occlusive patches for 12 days, as
previously described. The 2 areas were imaged at D0, D12 (end of the occlusion
period), D18, and D32 using the DermaInspect device by taking advantage of
intrinsic multiphoton signals from cells, and elastic and collagen fibers. The
following quantitative parameters were extracted using a recently developed 3D
image processing tool: epidermal thickness, normalized area of the dermoepidermal
junction (DEJ), global and z-distribution of melanin density. Main results are: (i) a
thickening of the epidermis on TEJ treated areas at D18 versus baseline (+9%; effect
size ¼ 0.7, moderate); (ii) a decrease in the DEJ undulation at D12 and D18 on
vehicle-treated areas versus baseline (effect size ¼ 0.7, moderate and 0.9, strong),
probably because of occlusion and that was not observed with TEJ; and (iii) a
progressive decrease in melanin density in the basal layers on TEJ treated areas [-22%
at D18 (effect size ¼ 0.4, moderate) and -37% at D32 (effect size ¼ 0.8, strong) versus
D0, and 29% (effect size ¼ 0.4, moderate) versus vehicle at D32] with a visible
decrease in the melanin induced fluorescence signals on the multiphoton images.
Although occlusion does not correspond to normal use, these results suggest an
effect of TEJ on the pigmentation of photodamaged skin which could contribute to
its antiaging effect. These findings will be confirmed by a long-term study under
open applications.
Supported by Procter & Gamble.
Commercial support: None identified.
Background: Signs of facial skin aging in women worldwide include fine lines and
wrinkles, but because of menopausal onset, women aged 55+ have unique
physiologic needs compared to women \48 years old. To address the need for
skin care products that alleviate these signs of facial skin aging for the 55+
postmenopausal female consumer, we evaluated a daily-use facial moisturizer
formulation containing a specifically prepared artichoke extract. In previous studies
with in vitro skin models, this specific artichoke extract was shown to positively
affect biomarkers associated with skin health and structure.
Methods: An independent double-blinded vehicle-controlled 12-wk facial study was
conducted in the United States (Cincinnati, OH) with women 55-65 years old and
women 40-48 years old, with moderate to moderately severe facial fine lines and
wrinkles. The subjects applied moisturizer twice daily in a split-face randomized
study design. The product tested was a cosmetic moisturizer formulation containing
a specifically prepared artichoke extract with a moisturizer base vehicle as control.
Skin appearance was evaluated at 0, 4, 8, and 12 wks by digital imaging and expert
grading. Grading of subjects for redness and dryness was conducted at all time
points.
Results: In this study, use of the cosmetic moisturizer formulation containing a
specifically prepared artichoke extract significantly improved the appearance of eye
area fine lines and wrinkles as compared to vehicle. The improvement was apparent
in the 55+ women at the 8 week time point evaluated by expert grading, and
increased in magnitude for the duration of product use (12 wks). The speed of
improvement was faster for the 55+ women than the younger women 40-48 years
old. No adverse effects (redness, dryness) compared to the vehicle product were
observed.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB25
P8123
P7817
Microegrowth factors for skin rejuvenation
Michael H. Gold, MD, Gold Skin Care Center, Nashville, TN, United States; Julie
Biron, Tennessee Clinical Research Center, Nashville, TN, United States
Background: Microegrowth factors are unique peptides with growth factorelike
activities. They stimulate the formation of extracellular matrix components
including collagens, elastin, and hyaluronic acid. Similarly as for protein growth
factors, microegrowth factors activity results after binding specific cell surface
receptors. Although their receptor binding affinity is lower than protein growth
factors, their low molecular weight makes them valuable alternatives for topical use
in skin rejuvenation.
Neohesperidin DHC combined with vetegal extracts modulate some
antiaging markers in an ex vivo model
Dominique Fagot, L’Oreal Research & Innovation, Aulnay sous Bois, France; Alice
Laurent-Lesaffre, L’Oreal Research & Innovation, Chevilly Larue, France; Beatrice
Renault, L’Oreal Research & Innovation, Chevilly Larue, France; Isabelle Bossant,
L’Oreal Research &Innovation, Chevilly Larue, France; Marie Helene Gaudinat,
L’Oreal Paris, Clichy la Varenne, France
Objective: The study aimed at evaluating the modulation of epidermal and dermal
skin markers on an artificially aged skin samples following topical applications of a
combination of neohesperidin DHC with Cicer arietum and Vigna aconitifolia
extracts.
Methods: Skin samples were obtained from plastic surgery and were artificially
‘‘aged’’ at D0 and D1 by topical applications of a class II dermocorticoid
(betamethasone 0.05%: 2 mg/cm2). Four groups were tested: (1) control skin; (2)
artificially ‘‘aged’’ skin without any further application, (3) positive control
(artificially ‘‘aged’’ skin treated with TGF-beta 5 ng/mL), and (4) artificially ‘‘aged’’
skin with a daily topical application at D1, D2, and D3 of a combination of
neohesperidin DHC at 30 M with C arietum at 0.2% and V aconitifolia at 0.3%
extracts. Histologic and immunohistologic analysis were performed: cell proliferation was analyzed by quantifying mitotic cells (KI67 marker); papillary extension
thickness was measured by image analysis of hematoxylineeosin (H&E) stained
samples. Laminin 5 and a 6 integrin at the DEJ level were quantified by
immunohistologic labeling. Histologic staining with alcian blue allowed glycosaminoglycans to be evaluated.
Results: ‘‘Aged’’ skin samples showed a significant decrease of the mitotic index,
epidermal thickness, laminin 5 expression, and a decreasing trend in a6 integrin
expression and in glycosaminoglycans quantity versus control skin. ‘‘Aged’’ skin
samples treated with the 3 ingredient combination showed a significant increase in
the expression of the mitotic index and in the papillary extension thickness versus
positive control. A strengthening of the DEJ was also observed with a significant
increase in laminin 5 expression versus positive control. An increase of the
epidermal anchorage was observed with a significant increase in expression of a 6
integrin versus positive control. These markers are both involved in adhesion of
epidermal stem cell environment to the basal membrane for optimal epidermal
renewal. An increase in glycosaminoglycans at the dermis level was also found.
Objective: To evaluate the safety and efficacy of a specific combination of
microegrowth factors for skin rejuvenation in humans. The combination of
microegrowth factors has been selected based on their properties to stimulate
collagen I, collagen III, collagen VII, elastin, and hyaluronic acid in human dermal
fibroblasts.
Methods: Forty-two females of skin types I to III with at least moderate signs of facial
wrinkles were enrolled in this IRB approved, randomized, vehicle controlled,
parallel group, double blind study. Subjects used an oil-in-water emulsion cream
with microegrowth factors for 6 months twice daily after a wash-out period of 2
weeks. Investigator evaluations included the assessment of periorbital and perioral
wrinkles with a 5-point photonumeric visual analogue score before and after 1, 2, 3,
and 6 months of treatment. Tactile roughness, skin pores, and skin tone were also
determined visually. Skin tolerability and subject’s self-evaluations by questionnaires
were further assessed. Primos analysis and Visia images were captured.
Results: The test product was well tolerated and significantly reduced periorbital
and perioral wrinkles starting after 2 months. Periorbital wrinkles improved (by at
least 1 unit) in 35% of the subjects after 1 month (from 2.9 6 0.5 before treatment to
2.6 6 0.6; mean 6 SD, n ¼ 20), 71% after 3 months (2.1 6 0.6; n ¼ 17), and 88%
after 6 months (1.8 6 0.4; n ¼ 17). Perioral wrinkles improved (by at least 1 unit) in
30% of the subjects after 1 month (from 2.7 6 0.6 before treatment to 2.4 6 0.6;
mean 6 SD, n ¼ 20), 47% after 3 months (2.2 6 0.5; n ¼ 17), and 71% after 6 months
(1.7 6 0.5; n ¼ 17).
Conclusion: This study indicated that a cream with microegrowth factors can be
used for skin rejuvenation. Additional studies are warranted in order to compare the
efficacy of microegrowth factor with standard, protein growth factor products.
Sponsored 100% by Neocutis, Inc.
Conclusion: This study demonstrated the benefits of the association of neohesperidin DHC with C arietum and V aconitifolia extracts in the positive modulation of
several biologic and histologic markers of skin aging ex vivo.
Commercial support: None identified.
P8132
Novel antioxidant serum with high antioxidant capacity: An ESR-based
study
Frank Dreher, PhD, Neocutis, Inc, San Francisco, CA, United States; Alan Olansky,
MD, Olansky Dermatology Associates, Atlanta, GA, United States; Jens Thiele,
MD, PhD, Dermatology Specialists, Inc, Oceanside, CA, United States
P8158
Mitigation of dysfunctional cellular bioenergetics in dermal fibroblasts by
niacinamide under oxidative stress conditions
John Oblong, PhD, The Procter & Gamble Company, Mason, OH, United States
Daily exposure of human skin to environmental insults, such as solar radiation,
pollution, and smoke, triggers numerous biologic processes that include oxidative
stress and inflammation, which can lead to dysfunction of cellular processes,
ultimately impacting tissue integrity and appearance. One of the main effects from
oxidative stress on cells is a diminished capacity of cellular bioenergetics. To better
understand changes in cellular metabolism caused by oxidative stress, glycolysis and
oxidative phosphorylation rates in human dermal fibroblasts were monitored in real
time under controlled nonlethal oxidative stress conditions. Hydrogen peroxide was
used as a surrogate stressor because numerous environmental stressors and intrinsic
aging trigger its production. H202 ranging between 0.5-3 mM caused a significant
decrease in glycolytic and oxidative phosphorylation rates along with cellular ATP
and NAD+ levels. Niacinamide (Nam) was found to protect and restore glycolytic
rates concurrent with restoring ATP to control levels. NAD+ levels were significantly
restored as well. Nam had an effective dose response range between 0.1-1.0 mM,
with maximal effects attained at 0.5 mM. Relative to oxidative phosphorylation,
niacinamide was able to provide a diminished but significant level of protection. A
glycolytic stress assessment of niacinamide’s effects on glycolysis under normal and
peroxide stress conditions showed a significant ability to mitigate the stress-induced
decrease in glycolytic rates but niacinamide was not able to restore spare glycolytic
capacity. Nam had no effect on restoring spare respiratory capacity. Testing with
FK866, a known NAMPT inhibitor, was found to significantly inhibit niacinamide
protective effects, supporting that niacinamide mechanism of action involves NAD+
synthesis. These results support ongoing in vitro research showing that niacinamide
has a protective effect on cellular metabolism, particularly glycolysis, under
oxidative stress conditions induced by H202 and that part of its mechanism of
action involves maintenance of NAD+ cellular pools.
Sponsored 100% by The Procter & Gamble Company.
AB26
Background: Apart from using sunscreens, supplementation of the skin with
topically applied antioxidants and thereby strengthening its antioxidative capacity
(AC) is an established approach in limiting oxidative stress induced skin damages.
The quantification of antioxidant capacity of an antioxidant preparation is, however,
a challenging task. For instance, decolorization assays including the Oxygen Radical
Absorbance Capacity (ORAC) have been recognized as artifact- prone, and also not
applicable for colored or opaque. A novel method based on electron spin resonance
(ESR) spectroscopy was described as more accurate and further allowing measuring
antioxidant capacity in colored or opaque samples, ex vivo, and in vivo.
Objective: To evaluate the AC of a novel antioxidant serum comprising 15% ascorbic
acid and 1% alpha-tocopherol combined with epigallocatechin gallate, dimethylmethoxy chromanol, and creatine in a silicon-oil based preparation; and to compare its
antioxidant capacity to other marketed antioxidant products using a novel ESRmethod.
Methods: AC of a novel antioxidant serum and the other antioxidant products was
determined by following the reducing activity against the stable test radical
diphenyl-picryl-hydrazyl with ESR-spectroscopy using the X-band ESR spectrometer
Miniscope MS 300 (Magnettech, Germany). The results were expressed in
antioxidative units (AU), where 1 AU corresponds to the activity of a 1 ppm solution
of ascorbic acid as a benchmark; and reaction time (minutes). Three different
batches of each product were tested.
Results: The AC of the novel antioxidant serum was with 156.866 6 13.497 AU
significantly higher than a test product comprising 15% ascorbic acid, 1% alphatocopherol and 0.5% ferulic acid, which reached 100.271 6 17.197 AU. Another
product comprising 10% ascorbic acid, 5% tetrahexyldecyl ascorbate, and a
combination of tocopherol and tocopherol acetate reached 69.237 6 3.799 AU.
The novel antioxidant serum further revealed the fastest reaction time of all three
products with 0.17 6 0.00 min as compared to 0.23 6 0.01 min for both other
products.
Conclusion: Using an ESR-based method to determine AC, a novel antioxidant serum
was shown to be of high antioxidant power and fast reaction time. Since this method
allows measuring the AC more accurately than ORAC, it should be preferentially
used to describe topical antioxidant preparations.
Supported 100% by Neocutis, Inc.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
P8010
Short-term and noninvasive assessment of antiaging effects of retinol
0.3% and retinoic acid 0.025% using in vivo multiphoton microscopy
Emmanuelle Tancrede-Bohin, MD, L’Oreal Research and Innovation - Centre de
Recherche Bioclinique, Paris, France; Ana-Maria Pena, PhD, L’Oreal Research and
Innovation, Aulnay sous Bois, France; Raquel Dalmaschio, PhD, L’Oreal Research
and Innovation - Centre de Recherche Bioclinique, Paris, France; Sebastien
Brizion, L’Or
eal Research and Innovation, Aulnay sous Bois, France; Steeve
Victorin, L’Oreal Research and Innovation - Centre de Recherche Bioclinique,
Paris, France; Therese Baldeweck, PhD, L’Oreal Research and Innovation, Aulnay
sous Bois, France
We previously showed that, in an occlusive patch test initially developed for
assessing the effects of topical retinoids on human skin, in vivo multiphoton
microscopy (MPM), a recent noninvasive skin imaging technique, could be used for
assessment as an alternative to invasive biopsies. The objective of this new study was
to confirm these results with a larger cohort of subjects. Accordingly, a randomized,
double-blind, monocentre comparative study was performed involving 20 volunteers, aged 50-65 years, with photodamaged skin. Two products, retinol (RO, retinol
0.3%, Skinceuticals) and retinoic acid 0.025% (RA, Retacnyl, Galderma) were applied
to the dorsal side of the forearm under occlusive patches for 12 days, as previously
described. A patch alone was applied to a third area as control. Evaluation of the 3
areas was performed at D0, D12, (end of the occlusion period), D18 and D32 using
MPM and other noninvasive techniques including colorimetry. The following
quantitative parameters were extracted from MPM images using recently developed
3D image processing tools: epidermal thickness, normalized area of the dermoepidermal junction (DEJ), melanin density. Main results (P \.05, with moderate to very
strong effect sizes) are: (1) a thickening of the epidermis on retinoid treated areas at
D12, D18, and D32 with RO and at D12, D18 with RA versus baseline and versus
control, with RO [ RA at D32. Cutaneous irritation which could be responsible of
edema was noted in 19 out of 20 RO-treated areas, and in 14 out of 20 RA-treated
areas at D12, but resolved within a few days and could not be responsible of
epidermal thickening observed at D32; (2) an increase in the DEJ undulation at D32
on RO treated area and at D12 on RA treated area versus baseline and versus control,
with RO [ RA at D32; (3) a decrease in melanin density at D12, D18, and D32 on RO
treated area and at D12 on RA treated area versus baseline, associated with a visible
whitening. This study shows that such short term protocol combined with in vivo
multiphoton microscopy allows some cutaneous effects induced by retinoids to be
detected, followed over time posttreatment, and compared noninvasively.
ARTS, HISTORY, AND HUMANITIES OF
DERMATOLOGY
P8171
Anthropodermic bibliopegy: Lessons from a different sort of dermatologic text
Navya Nambudiri, MBBS, Cochin Cooperative Medical College, Cochin, Kerala,
India, India; Vinod Nambudiri, MD, MBA, Harvard Combined Dermatology
Program, Brookline, MA, United States
The practice of anthropodermic bibliopegy—the use of human skin for the binding
of books and manuscripts—dates back several centuries. Examples of anthropodermic texts have been reported from nations in Europe, Asia, and the Americas
since the late 16th century. The selection of individuals whose skin would be used in
the process ranged from authors and scientists arranging for willing donation upon
their death to the corpses of criminals and the infirm. Several texts from the 17th,
18th, and 19th centuries bound in tanned, leatherized human skin are preserved and
held in private and academic collections around the world. The preservation of such
texts in modern libraries provides a unique and intriguing series of works from both
an academic and humanistic standpoint from which dermatologists, historians, and
anthropologists can learn. We investigated an anthropodermic book in the
collection of the Houghton Library at Harvard University dating to the mid-19th
century. The text is a French manuscript from the 1880s that focuses on the afterlife
and theories of the human soul. The author of the text, in an inscription along with
the book, stated his belief that the subject of the manuscript warranted
juxtaposition with a binding of human skin. On examination of the bookbinding,
numerous follicular ostia are clearly visible and consistent with the author’s
description. While focal areas of dark pigmentation are present on the binding,
these do not show any melanocytic pattern on epiluminescence microscopy, and
are more consistent with variations in the literal ‘‘skin tanning’’ process. Two other
works in the collection of the Harvard University libraries which are putative
antropodermic texts dating from 16th century Spain and France were also
examined. While an uncommon undertaking, anthropodermic bibliopegy represents an historical practice of interest to dermatologists and provides insights into
the preservation of and fascination with human skin over the last several centuries.
Commercial support: None identified.
Commercial support: None identified.
P8499
How common is ‘‘common?’’ The frequency and precision of the terms
‘‘common’’ and ‘‘rare’’ in the dermatologic literature
Lucy Fu, Department of Dermatology, Emory University School of Medicine,
Atlanta, GA, United States; Benjamin Stoff, MD, Department of Dermatology,
Emory University School of Medicine, Atlanta, GA, United States; Robert
Swerlick, MD, Department of Dermatology, Emory University School of
Medicine, Atlanta, GA, United States; Suephy Chen, MD, MS, Department of
Dermatology, Emory University School of Medicine, Atlanta, GA, United States
Background: Academic medical journals are the primary information source for
health care providers and form the foundation of patient education toward the goal
of shared decision making. Readers may assume that language used to convey such
information is objective and precise. However, scrutiny of medical language in many
domains, particularly related to probability, reveals subjectivity and imprecision.
This scrutiny has not been applied to the dermatologic literature.
P8348
Topically applied human like epidermal growth factors in aging skin:
Randomized, placebo controlled trail by evaluating skin physiology and
skin surface parameters
Meike Streker, PhD, University of Hamburg, Hamburg, Germany; Martina
Kerscher, MD, University of Hamburg, Hamburg, Germany
Background: Skin aging is mediated by the effect of both intrinsic and extrinsic aging
having biochemical and molecular pathways. Epidermal growth factors are
regulatory proteins that mediate signaling pathways between and within cells and
directly initiate activity on skin repair. According to their role in skin repair there is a
big interest regarding their role in skin rejuvenation.
Methods: In this randomized, half-side, placebo controlled trial of 8 weeks’ duration,
30 healthy females aged 30 to 65 years were included. Serum and vehicle were
applied twice a day at 1 side of the face; allocation of treatment side was at random.
Efficacy was assessed by using a 3D surface imaging analysis systems, as well as
biophysical measurements for skin physiology and surface parameters.
Results: Clinical evaluation shows a clear improvement in skin roughness and
wrinkle volume. Moreover skin thickness increased and density and skin elasticity
improved significantly.
Objective: To establish the frequency of use of terms of probability, ‘‘common’’ and
‘‘rare,’’ in recent dermatologic literature, to determine whether use of these terms
are specified by a precise number or numeric range, and to compare results to
literature from internal medicine.
Methods: All peer-reviewed articles spanning 5 years (Jan 2008 e Dec 2012) were
reviewed from 2 journals: Archives of Dermatology (AD) and Archives of Internal
Medicine (AIM)— totaling 318 and 840 manuscripts, respectively. The PDF file of
each article was searched for the terms ‘‘common’’ and ‘‘rare.’’ Each occurrence was
documented and analyzed for (a) reference to a specific numeric reference value, (b)
whether the specific value was stated within the paper or externally in a citation,
and (c) the range of values (probabilities) that the word was intended to represent.
Probabilities and percentages were converted to decimals for consistency. Uses as
part of a title or other proper phrase were excluded.
Results: There were 713 instances of ‘‘common’’ (2.24 per paper) in AD; 1647 (1.96
per paper) in AIM. There were 204 instances of ‘‘rare’’ (0.64 per paper) in AD; 273
(0.33 per paper) in AIM. Only 174 of the 713 instances (24.4%) of ‘‘common’’ in AD
had a numeric reference; 377 of 1647 (22.9%) in AIM. Only 14 of 204 (6.9%)
instances of ‘‘rare’’ in AD had a numeric reference; 26 of 273 (9.5%) in AIM. The
range of values that ‘‘common’’ represented was 4 3 10-6 e 1; which overlapped
with ‘‘rare,’’ 10-3 e 0.3.
Conclusion: EGF serum improves age-related skin changes as assessed clinically and
by biophysical measurements. This might be caused by a stimulation of epidermal
cells and a neosynthesis of collagen and elastin. Moreover, treatment with EGF is
accompanied with a high patients’ satisfaction and a high tolerability.
Discussion: There appears to be substantial subjectivity and imprecision in the use
of the terms ‘‘common’’ and ‘‘rare’’ in the academic journals in dermatology and
internal medicine. The majority of uses did not refer to specific numeric ranges. For
those that did, ranges were broad and overlapping (ie, common and rare referred to
similar frequencies). These findings raise concerns about rhetoric in scientific
medical writing.
Commercial support: None identified.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9221_9226_proof 4 February 2014 9:51 am
AB27
BASIC SCIENCE
P7813
A novel lipid complex that promotes skin hydration and barrier function
Tiffany Oliphant, MS, Floratech, Chandler, AZ, United States; Robert Harper, PhD,
Harper & Associates, La Jolla, CA, United States
Background: A novel lipid complex, designed to mimic human skin lipids, derived
from botanical sources consisting of jojoba (Simmondsia chinensis), macadamia
(Macadamia integrifolia), and olive (Olea europaea) oils, was evaluated for skin
hydration and restorative barrier function properties in healthy individuals.
Methods: Two small, IRB approved, randomized, double blinded, vehicle-controlled
studies (12 to 15 subjects each) were carried out under controlled environmental
conditions in order to evaluate the effectiveness of this lipid complex on increasing
skin hydration and restoring barrier function. The following lotion test articles were
evaluated in both studies: vehicle, vehicle + lipid complex, vehicle + Ceramide II,
and vehicle + lipid complex + Ceramide II. The first study involved 1 application of
each of the test articles to the lower legs of subjects with dry legs, and Corneometer
measurements were taken at baseline and every hour for 4 hours posttest article
application. The second study used acetone extraction of the stratum corneum on
forearm skin sites to produce a defective skin barrier. Transepidermal water loss
(TEWL) was determined at baseline, after completion of the extraction process, and
30 and 60 minutes posttest article application.
Results: The skin hydration data show that vehicle + lipid complex produced a
statistically significant increase in skin hydration over vehicle and vehicle +
Ceramide II at all time points. Vehicle + lipid complex + Ceramide II also produced
a statistically significant increase in skin hydration over all of the other test articles at
all time points. With regard to barrier function, vehicle + lipid complex produced a
statistically significant increase in barrier recovery at both time points over vehicle
and vehicle + Ceramide II. Vehicle + lipid complex + Ceramide II also statistically
significantly increased barrier recovery and showed an added benefit over that of
vehicle + lipid complex. Vehicle + Ceramide II alone did not increase skin hydration
and produced only a slight increase in barrier recovery over vehicle.
P8231
Activin suppresses LPS-induced Toll-like receptors, cytokines, and nitric
oxide expression by inhibiting activation of NF-kB and MAPK pathways in
normal human melanocytes
Young Il Kim, Medical Science Research Institute, Kyung Hee University Medical
Center, Seoul, Korea, Seoul, South Korea; Jeong Hwee Choi, Department of
Dermatology, College of Medicine, Kyung Hee University, Seoul, Korea, Seoul,
South Korea; Min Kyung Shin, Department of Dermatology, College of Medicine,
Kyung Hee University, Seoul, Korea, Seoul, South Korea; Mu-Hyoung Lee,
Department of Dermatology, College of Medicine, Kyung Hee University, Seoul,
Korea, Seoul, South Korea; Myong Il Bae, Department of Dermatology, College of
Medicine, Kyung Hee University, Seoul, Korea, Seoul, South Korea; Seung-Won
Park, Department of Biotechnology, Catholic University of Daegu, Daegu, Korea,
Seoul, South Korea
Objectives: Activins are dimeric growth and differentiation factors which belong to
the transforming growth factor-beta (TGFb) superfamily of structurally related
signaling protein. We examined the mechanism how activin regulates transcription
of lipopolysaccharide (LPS)-induced Toll-like receptors (TLRs), cytokines, and
inducible nitric oxide synthase (iNOS) in human melanocytes, and the involvement
of nuclear transcription factor-kB (NF-kB) and mitogen-activated protein kinase
(MAPK) pathways.
Methods: Normal human melanocytes were pretreated for 20 h with activin A before
exposure to LPS for 4 h. Total RNA was purified from cultured cells and real-time PCR
procedures were performed. Also we conducted immunoblot analysis to know the
expression levels of proteins.
Results: LPS increased mRNA expressions of TLRs (1-10) and cytokines (IL-1b, IL-6,
IL-8, IL-10, TNF-a), and enhanced mRNA and protein expression of iNOS. Activin
inhibited LPS-induced mRNA expressions of TLRs and cytokines, and decreased
mRNA and protein expression of LPS-induced iNOS. Also activin suppressed
NF-\kappaB p65 activation and blocked IkBa degradation in LPS-stimulated
melanocytes, and reduced LPS-induced p38 MAPK and MEK/ERK activations.
Conclusions: This research has shown that a unique complex of botanically derived
lipids can have a positive effect on skin hydration and barrier recovery, and that
Ceramide II may potentiate the effect. More research into the specificity of the
Ceramide II is underway.
Conclusion: This study demonstrated that activin inhibited expression of genes of
TLRs, cytokines, and iNOS in LPS-activated normal human melanocytes. Moreover,
the antiinflammatory effect of activin was mediated through suppressing the
activation of NF-kB and MAPKs signaling pathways in LPS-activated normal human
melanocytes, thus resulting in the reduced expression of TLRs, cytokines, and nitric
oxide.
Sponsored 100% by Floratech.
Commercial support: None identified.
P8501
P7880
A potential association between soluble adenylyl cyclase and Ras
activation in the control of metabolism in transformed fibroblasts
Michelle E. Park, Weill Cornell Medical Center, New York, NY, United States;
Jonathan H. Zippin, MD, PhD, Weill Cornell Medical Center, New York, NY,
United States
Cancer cells exhibit an abnormal metabolic phenotype known as the Warburg
effect. This metabolic phenotype is driven by activation of RAS and the MAPK
signaling pathway. Another signaling pathway instrumental in regulating metabolism is the cyclic adenosine monophosphate (cAMP) pathway. Recently these 2
signaling pathways were shown to cooperate to alter metabolism and growth in
transformed cells. K-Ras transformation of fibroblasts led to a Warburg-like effect in
which cells were sensitive to low glucose levels or glycolytic inhibitors. We have
found that cells absent of soluble adenylyl cyclase (sAC), a source of cyclic AMP, also
exhibit glucose sensitivity. At high glucose concentration, sAC knock out (KO) cells
proliferated almost twice as much as wild type (WT) cells after 72 hours, while there
was significantly less growth of sAC KO cells as compared to WT cells in media that
contained no glucose. Moreover, incubation in media containing 2-deoxyglucose (2DG), an inhibitor of glycolysis, led to as much as 75% inhibition of KO cell growth as
compared to 40% inhibition in WT cells, whereas inhibitors of mitochondrial
respiration (oligomycin and bromopyruvate) did not cause significant differences in
cell growth between the two lines. This difference in sensitivity to glucose levels and
glycolytic inhibitors, but not to inhibitors of mitochondrial respiration, suggests that
decreased sAC-dependent cAMP levels leads to a shift in metabolism whereby an
anaerobic pathway is favored akin to the Warburg effect.’To determine whether RAS
is important for the altered metabolic requirements in sAC KO cells, we established
stable clones overexpressing a dominant negative RAS guanine nucleotide exchange
factor (DNGEF). When overexpressed, this protein decreased RAS GTP levels and
rescued KO cell death caused by low glucose levels or inhibition of glycolysis by
2-DG, suggesting that RAS activity is important for the altered metabolic demands in
KO cells. Taken together, these data suggest that sAC in a RAS-dependent manner
modulates cell metabolism. Because of the importance of RAS and cellular
metabolism in cancer, we predict that elucidation of this pathway may lead to the
development of novel targets of cancer therapy.
Commercial support: None identified.
AB28
Bioinformatics approaches to understand the molecular basis of skin
aging and in vitro effects of cosmetic ingredients
Rosemarie Osborne, PhD, The Procter & Gamble Company, Mason, OH, United
States; Jay Tiesman, PhD, The Procter & Gamble Company, Mason, OH, United
States; Lisa Mullins, MS, The Procter & Gamble Company, Mason, OH, United
States; Makio Tamura, PhD, The Procter & Gamble Company, Mason, OH, United
States; Michael Robinson, PhD, The Procter & Gamble Company, Mason, OH,
United States; Robert Binder, PhD, The Procter & Gamble Company, Mason, OH,
United States
Background: Availability of multidimensional omics data in modern biologic and
medical science has made bioinformatics techniques a decisive capability for
knowledge discovery from large amounts of experimental data. Various bioinformatics and data mining techniques can be applied in analyzing omics data to provide
deeper understanding of fundamental skin biology processes, including metabolism
and aging. These approaches can also be used to define in vitro skin effects of skin
care technologies. A typical omics dataset is one created using DNA microarrays,
which provide a snapshot of genome-wide transcriptomic activities and a whole
genome expression profile of in vitro effects of skin care technologies. In the current
work, a battery of bioinformatics techniques was used to analyze transcriptomics
data from studies of skin care ingredients in vitro.
Methods: Bioinformatics techniques included overrepresentation analysis, biologic
pathway analysis, clustering analysis, pattern matching algorithms, text mining, and
custom data mining algorithms. These techniques enabled identification of biologic
processes/pathways and gene expression patterns associated with aged skin, from
analysis of transcriptomics data from clinical specimens of photo- and intrinsically
aged skin. The bioinformatics approaches were applied also to evaluate in vitro
epidermal keratinocyte and dermal fibroblast responses to cosmetic ingredients.
Results: In vitro skin cell evaluation of niacinamide indicated effects on pathways
associated with aging skin: carbohydrate homeostasis, glucose homeostasis, cellular
iron ion homeostasis, second messenger synthesis, cellecell adhesion and senescence. An olive derivative affected pathways associated with cholesterol and lipid
synthesis, skin barrier and moisturization, repair of UV damage, relief of oxidative
stress and energy balance. Dill extract affected pathways associated with glucosamine synthesis, ceramide and membrane lipid synthesis, hydration and antioxidant
protection.
Conclusions: Advanced bioinformatics approaches identified molecular processes
and pathways associated with aging skin. These approaches also identified aging
processes affected in vitro by cosmetics ingredients including niacinamide, olive
derivative and dill extract, as an aid to address processes related to maintaining a
healthy metabolic balance, providing higher stress tolerance, and smoothing the
appearance of uneven texture in aging skin.
Sponsored 100% by The Procter & Gamble Company.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8169
P8371
Biophysical effects of a novel in-shower skin care formulation with 5%
dexpanthenol—Results of a vehicle-controlled in vivo study
Jane Djamil, Beiersdorf AG, Hamburg, Germany; Anette Buerger, Beiersdorf AG,
Hamburg, Germany; Frank Rippke, MD, Beiersdorf AG, Hamburg, Germany;
Joachim Degwert, PhD, SIT Skin Investigation and Technology, Hamburg,
Germany; Teresa Weber, PhD, Beiersdorf Inc, Wilton, CT, United States
Combining an TRPV1-antagonist with the antiinflammatory flavonoid
licochalcone A improves subjective and objective symptoms of sensitive
skin: Results of 2 double-blind, vehicle-controlled in vivo studies
Sarah Hiddemann, Beiersdorf AG, Hamburg, Germany; Andrea Michaela
Schoelermann, PhD, Beiersdorf AG, Hamburg, Germany; Gitta Neufang, PhD,
Beiersdorf AG, Hamburg, Germany; Teresa Weber, PhD, Beiersdorf Inc, Wilton,
CT, United States; Ulrich Scherdin, MD, Beiersdorf AG, Hamburg, Germany
Sensitive skin is one of the most common skin conditions, with more than 50 % of
adults claiming to have sensitive skin. However, the scientific basis for heightened
skin sensitivity is not well understood. An impaired skin barrier and an increased
susceptibility to endogenous and exogenous stressors triggering inflammatory
processes have been identified as major contributory factors, causing redness and
dryness, the visible signs of sensitive skin. Recently, the hyperresponsiveness of
sensory neurons was revealed to contribute to skin sensitivity. Therefore, the
lowered activation threshold of the thermo Ca2+ channel TRPV1, located on
sensory neurons as well as on skin cells like keratinocytes and fibroblasts, was
shown to play an important role, correlating with subjective symptoms like tingling,
burning, or stinging. To provide optimum skin care for sensitive skin, it is important
to address multiple factors known to contribute to this skin condition. To investigate
the efficacy of novel skin care formulations for individuals with sensitive skin,
formulations containing the TRPV1 antagonist 4-t-butylcyclohexanol alone, or in
combination with antiinflammatory Licochalcone A were tested in double-blind,
randomized, vehicle-controlled in vivo studies. Using a modified stinging test (n ¼
24) with nasolabial application of capsaicin (40 ppm), 4-t-butylcyclohexanol was
observed to significantly suppress capsaicin induced stinging on a VAS (verum: 1.9;
vehicle: 3.7; P \.05), thus alleviating subjective skin symptoms by soothing the
hyperresponsiveness of sensory neurons. In a razor burn test with 38 volunteers,
after mechanical irritation leading to barrier disruption and inflammation of the
skin, the combination of licochalcone A and 4-t-butylcyclohexanol visibly and
significantly reduced redness compared to the vehicle control (visual assessment of
redness intensity—verum, 3.1; vehicle, 2.0; P \.05; spectroscopic measurement of
a-values—verum, 1.1; vehicle, 1.4; P \ .05). Taken together, the results provide
evidence that the TRPV1 antagonist 4-t-butylcyclohexanol and its combination with
antiinflammatory licochalcone A relieve subjective and objective symptoms of
sensitive skin.
Modern skin cleansing habits like daily showering with the regular use of surfactants
can harm the skin barrier function, especially in sensitive skin sufferers. Adjunctive
application of moisturizers is commonly recommended after showering in order to
restore an intact barrier function; however, the acceptability of lotion application
can be limited by the need to wait for product absorption before dressing. We
therefore developed a novel formulation containing 5% dexpanthenol to be applied
in the shower directly after skin cleansing enabling immediate dressing after towel
drying. In order to elucidate the biophysical effects of the formulation, we
conducted a double-blind, vehicle-controlled in vivo study. Forty volunteers
(21-50 yrs) applied the formulation with dexpanthenol or its vehicle in the shower
daily for 2 weeks, with weekly assessments of skin hydration and barrier function.
Compared to its vehicle, the formulation with dexpanthenol induced a significant
decrease of the TEWL after 1 and 2 weeks of application. The vehicle alone
significantly increased skin hydration after 1 and 2 weeks, which was further
significantly enhanced by the dexpanthenol formulation. No adverse reactions were
observed. In summary, the new in-shower formulation objectively counteracts the
desiccating effect of daily showering and significantly strengthens skin barrier
function.
Supported by Beiersdorf AG.
Supported by Beiersdorf AG.
P8510
Chronological changes in facial wrinkles and texture in a longitudinal
study
Rosemarie Osborne, PhD, The Procter & Gamble Company, Mason, OH, United
States; James Li, MS, The Procter & Gamble Company, Cincinnati, OH, United
States; Joseph Kaczvinsky, PhD, The Procter & Gamble Company, Cincinnati,
OH, United States; Marcia Schnicker, MS, The Procter & Gamble Company,
Cincinnati, OH, United States; Michael Marmor, MS, The Procter & Gamble
Company, Cincinnati, OH, United States
Background: Environmental differences from seasonal change can affect skin
attributes. For example, seasonality effects from UV exposure are often observed
in skin pigmentation. However, data on seasonal, weekly or daily changes for
wrinkles and uneven texture are limited. A year-long study was conducted to
determine the effect of inherent chronologic variation on the appearance of facial
aging attributes.
Methods: A 54-week study was conducted. Twelve white female subjects
(Cincinnati, Ohio USA) were evaluated, 40-65 years old and Fitzpatrick skin types
I-III, with moderate to moderately severe periorbital wrinkles and facial texture.
Subjects applied a moisturizing lotion twice daily during the 2-week preconditioning and 52-week treatment periods. Eye-area fine lines and wrinkles and cheek-area
bumpy texture were evaluated by expert grading and image analysis of digital facial
images, at baseline and weekly (33 MWF) thereafter. During a week in the summer
and winter seasons, additional images were obtained 33/day (morning, midday,
evening) every day. Subjects also completed wellness questionnaires (eg, sleep,
alcohol use, exercise).
Results: At baseline and throughout the study, subjects had more fine lines, wrinkles,
and texture on the left side as compared to the right side of the face, by both expert
grading and image analysis. This trend was not observed in separate evaluations of
Chinese women in China. In winter, fine lines, wrinkles and texture appeared to be
less pronounced at noon than in the morning or evening; there was little change
across different days during the week. Fine lines and wrinkles were worse in winter
than in summer, and fluctuated in the fall and spring seasons; the increased
appearance during the winter did not return to baseline in the spring. Seasonal
effects were not as pronounced for texture. Changes in fine lines and wrinkles were
positively correlated with change in outdoor temperature at different times of year.
Conclusions: These results indicate that signs of facial aging, including fine lines,
wrinkles and uneven texture, are subject to change on a chronologic basis, including
daily and seasonally. It is likely that environmental conditions such as sun exposure
on the left side of face from driving (in the United States) can further exacerbate
facial skin aging. These results support the premise that skin care products and
regimens need to address changing needs of skin on a daily spanning to a seasonal
basis.
Sponsored 100% by The Procter & Gamble Company.
P8482
Confirmation of shampoo mildness in human skin culture models
Rosemarie Osborne, PhD, The Procter & Gamble Company, Mason, OH, United
States; Hans Raabe, PhD, Institute For In Vitro Sciences, Gaithersburg, MD,
United States; Maria Cristina Castan, MS, Procter & Gamble Service GmbH,
Darmstadt, Germany; Mark Brown, MS, The Procter & Gamble Company,
Cincinnati, OH, United States; Regina Weber, MS, Procter & Gamble Service
GmbH, Darmstadt, Germany
Background: Human skin cell models have been proposed as appropriate models to
evaluate the skin compatibility of personal care products and ingredients. It is
especially important to confirm the skin compatibility of surfactant-based personal
cleansing products, such as shampoos. The goal of the current work was to evaluate
a set of shampoo prototype formulations in a battery of in vitro skin models to
determine if the in vitro models have capacity to distinguish the skin compatibility of
the formulations.
Methods: In vitro skin tests evaluated included 3 protocols evaluating human skin
keratinocytes, including neutral red uptake and neutral red release as indicators of
cytotoxicity, and Cytosensor Microphysiometer as an indication of cellular
metabolism. In these protocols, the shampoo formulations were evaluated in
dose-response experiments. In addition, 2 tests evaluated topical application of
shampoo solutions onto human skin epidermal equivalents. These skin models are
tissue engineered from human epidermal keratinocytes, and contain a stratified
epidermis including a stratum corneum. Effects of shampoo solutions on cellular
(MTT) metabolism and cytokine expression were evaluated in the epidermal
equivalent cultures.
Results: In initial evaluation, all 5 in vitro skin tests were used to test a high and a low
benchmark shampoo prototype formulation. The results indicated that the 2
epidermal equivalent protocols produced the best distinction between the 2
benchmark prototypes. In follow-up testing, 10 shampoo formulations covering a
range of skin mildness were evaluated in the 2 epidermal equivalent protocols. Both
of the topical epidermal equivalent tests (time-course and rinse-off protocols with
metabolism endpoints) provided data that rank ordered the degree of response, and
could be used to classify the mildness of the shampoo prototypes. Cytokine
expression in the rinse-off protocol confirmed the metabolism results.
Conclusions: These results indicate that in vitro human skin cultures, particularly
epidermal equivalent cultures, can be used to confirm the skin compatibility of
prototype shampoo formulations before clinical evaluations. An added advantage of
the stratified epidermal cultures is that they allow topical application of test
materials, mimicking in vivo exposures.
Sponsored 100% by The Procter & Gamble Company.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB29
P8639
P7646
Dermatologic assessment of the skin tolerance of a new male razor used in
body shaving
Dana Pedersen, PhD, Gillette P&G Global Product Stewardship, Boston, MA,
United States; Kristina Vanoosthuyze, PhD, Gillette Technology Centre, Reading,
United Kingdom; Pamela Zupkosky, Gillette Shaving Technology Laboratory,
Boston, MA, United States
Dermatologic benefits of a botanical oilebased skin care regimen
Cara Bondi, MPH, MS, Seventh Generation, Inc, Burlington, VT, United States;
Heather Beach, MS, Seventh Generation, Inc, Burlington, VT, United States; Heidi
Raatikainen, Seventh Generation, Inc, Burlington, VT, United States; Jennifer
McDonald, Seventh Generation, Inc, Burlington, VT, United States; Shannon
Lenox, Seventh Generation, Inc, Burlington, VT, United States
Background: Body grooming is an increasingly common practice in men. In a recent
study of US men, 28% removed body hair below the neck. Shaving is conducted in
many areas of the body, including chest, back, legs, underarms, and groin. The
choice of implement used to remove hair in the different parts of the body can be
difficult, both for the consumer and for the physician who is consulted about this. A
new male razor has been manufactured to allow effective and comfortable hair
removal in all of these varied areas.
Background: Natural daily skin care regimens have significantly increased in
popularity. Though many formulas do not contain botanically based ingredients,
those that do typically use active isolates from botanical oils. As such, few data are
available regarding the dermatologic benefits of formulated skin care products based
on unmodified botanical oils. In an effort to characterize the dermatologic profile of
such formulations, clinical evaluations of a facial cleanser, facial moisturizer, and
facial serum featuring unmodified botanical oils were conducted.
Methods: HRIPTs of a moisturizer, cleanser, and serum containing botanical oils
were conducted using standard methodology. Comedogenicity of a moisturizer,
cleanser, and serum containing botanical oils was evaluated at baseline, week 2, and
week 4 and analyzed using the Student t test (P \ .05). A Corneometer study
evaluated the acute moisturization of a lotion and serum containing botanical oils
and a traditional emulsion-based moisturizer. Measurements were taken at baseline
and 2, 4, and 8 hours and analyzed using a 2-way ANOVA (P \ .05). A
transepidermal water loss study evaluated the effects of a botanical oilebased
cleanser and 2 traditional surfactant-based gel facial cleansers. Measurements were
at taken baseline, 2 hours, and 4 hours and analyzed using a 2-way ANOVA (P\.05).
Objective: To assess how a manual body grooming razor is tolerated by men who
body groom at least once per week during a 6-week period. The razor has been
ergonomically designed for body shaving by adjusting to body concave curves and
contours.
Methods: A 42-day study was conducted amongst 39 male volunteers who body
groom (shave) underarms, chest, and/or stomach and groin at least 1 time per week.
Each of these areas were examined and graded by a dermatologist on day 1 (before
the first shave) and on day 42 (after the last shave). Grading was done on a 4-point
scale (0 ¼ none; 1 ¼ slight; 2 ¼ moderate; 3 ¼ severe) for visual signs of erythema,
dryness, papules, peeling, hyperpigmentation and edema.
Results: None of the symptoms increased from baseline. At the end of the study,
across all examined areas (including groin), several of the attributes scored ‘‘0’’
(none) and the average score of all attributes on all examined areas remained below
1. There was no more than mild erythema, no greater than baseline, reported during
the study. The dermatologist concluded that the tested body grooming razor was
well tolerated and safe to use for men who body groom.
All authors are employees of P&G.
Results: TEWL and Corneometer data show that the formulations containing
botanical oils enabled the skin to retain water and maintain barrier function better
than products using traditional surfactant or emulsion chemistries. This is not
unexpected, because botanical oils have a similar composition to the macromolecules of the skin moisture barrier. The major barrier to an oil-based skin care regimen
is typically the concern that oil can be comedogenic, leading to comeodones and
acne. However, these data show that well formulated products consisting entirely of
or containing blends of botanical oils will not result in comeodone formation, even
with long term daily use. In addition, these data show that the botanical oilebased
formulas tested did not produce primary or cumulative irritation and did not result
in allergic contact sensitization. As such, these data suggest that a skin care regimen
using products based on unmodified botanical oils may have advantages over a
traditional surfactant- and emulsion-based skin care regimen, although additional
research is required.
This research was fully sponsored by Seventh Generation, Inc.
P8131
P8670
Dermatologic assessment of the skin tolerance of shaving with a 5-blade
razor with additional lubrication by women with sensitive skin
Dana Pedersen, PhD, Gillette P&G Global Product Stewardship, Boston, MA,
United States; Kristina Vanoosthuyze, PhD, Gillette Technology Centre, Reading,
United Kingdom; Pamela Zupkosky, Gillette Shaving Technology Laboratory,
Boston, MA, United States
Background: Sensitive skin is a common problem among men and women. The
management and care of sensitive skin can be very difficult, both for the consumer
and for the physician who is consulted about this. Women with sensitive skin can
typically experience dryness, redness, burning, stinging. and itching associated with
shaving.
Objective: To assess how a manual 5-bladed razor with a protective lubricating ring
(which surrounds the 5-blade shaving surface) is tolerated by women with selfassessed sensitive skin under conditions of shaving their legs and underarms at least
3 times per week over a 4-week period. The razor releases extra lubrication to limit
friction of the cartridge components with skin and improve shaving comfort.
Methods: A 28-day study was conducted amongst 35 female volunteers with selfassessed sensitive skin. The legs and underarms were examined and graded by a
dermatologist on day 1 (before the first shave) and on day 28 (after the last shave).
Grading was done on a 4-point scale (0 ¼ none; 1 ¼ slight; 2 ¼ moderate; 3 ¼ severe)
for visual signs of erythema and dryness. The panelists graded their subjective
symptoms of burning, stinging, itching, and soreness on a similar scale and at the
same time points and body areas.
Results: The dermatologist concluded that the razor was well tolerated and safe to
use by women with self assessed sensitive skin..There were no adverse events
reported and the attributes evaluated remained at baseline or showed improvement
during the course of the study. The final average scores across all attributes were
below 0.5 for the examined areas.
All authors are employees of P&G.
AB30
Distribution of corneodesmosomes on superficial corneocytes differs
between infants and adults: A new look at the stratum corneum
maturation
Marek Haftek, University Lyon 1, Lyon Cedex, France; Beatrice Burdin, University
Lyon 1, Villeurbanne Cedex, France; Caroline Baudouin, Laboratoires
Expanscience, Epernon Cedex, France; Clarence de Belilovsky, Laboratoires
Expanscience, Epernon Cedex, France; Joachim Fluhr, Charite University Clinic,
Berlin, Germany; Philippe Msika, Laboratoires Expanscience, Epernon Cedex,
France
Introduction: Maturation of the epidermal barrier in the infancy and its evolution
during the senescence and in diseases have an important impact on the overall skin
appearance and function. Among other actors, corneodesmosomes play a critical
role in the stratum corneum (SC) cohesion and skin barrier function. We propose a
new ultrastructural approach with immunodetection of corneodesmosin to explore
the organization of superficial SC in infants and children.
Methods: D-squame adhesives were used to collect the most superficial corneocytes
from the volar face of forearms in 4 age groups of healthy infants and adults (n ¼ 5,
each): 5-6 weeks old; 12-18 months old; 4-5 years old, and 20-35 year old adults. The
samples were labeled with an anticorneodesmosin antibody (Abnova) and goat
antimouse IgG 1nm immunogold (Amersham) amplified with silver enhancement
kit (British BioCell). D-squame fragments were then examined in partial vacuum
(1 Torr) at 30 kV with a Quanta 250 FEG scanning microscope operating at backscattered and secondary electron modes. Digital pictures of isolated corneocytes
and of nondissociated cell packages were used for evaluation of the cell size and
corneodesmosome distribution. ImageJ free-access software was used for quantitative studies. ManneWhitney test was used for the statistical analysis.
Results: Surface relief of the samples was clearly appreciable with the back-scatter
mode whether the immunogold labelling signal was better visible using the
secondary electrons. The labeling specifically localized to the disrupted corneodesmosome structures distributed mainly on the lateral rims of the flattened cells.
Percentage of corneocytes presenting additional labelling at the area of the central
plateau was significantly lower in the youngest group (1.38 6 0.08) vs. 3 other agegroups (8.90 6 1.78, 8.36 6 0.74, and 7.34 6 0.93, respectively; P \.01). In
young babies, corneocytes occurred in thick and irregular packages, strikingly
contrasting with the even cell distribution in the older age groups. Projected area
of the individual cells progressively increased with age from 646.3 6 52.2 m2 at
5-6 weeks to 895.5 6 67.8 m2 at the adult age (P \.01).
Conclusion: Labeling of corneodesmosomes, cell distribution on D-squames, and
size of the superficial corneocytes differed significantly between the first weeks of
life and the later maturation stages. This reflects a relative immaturity of the
epidermal barrier under the age of 1 year.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P7778
P8332
Durable rough skin phantoms for optical modeling
Diana Diao, Vancouver Coastal Health Research Institute and Department of
Dermatology and Skin Science, University of British Columbia, Vancouver,
Canada; David McLean, Vancouver Coastal Health Research Institute and
Department of Dermatology and Skin Science, University of British Columbia,
Vancouver, Canada; Gurbir Dhadwal, Vancouver Coastal Health Research
Institute and Department of Dermatology and Skin Science, University of
British Columbia, Vancouver, Canada; Harvey Lui, Vancouver Coastal Health
Research Institute and Department of Dermatology and Skin Science, University
of British Columbia, Vancouver, Canada; Lioudmila Tchvialeva, Vancouver
Coastal Health Research Institute and Department of Dermatology and Skin
Science, University of British Columbia, Vancouver, Canada; Tim Lee, Vancouver
Coastal Health Research Institute and Department of Dermatology and Skin
Science, University of British Columbia, Vancouver, Canada
Background: When skin is illuminated by a low coherence laser, the remitted laser
interference pattern contains information on both surface roughness and bulk optical
properties of the skin. This technique can potentially be applied in vivo to
differentiate skin lesions. In order to further improve the accuracy of this technique,
additional studies focusing on lighteskin interactions are required. Skin phantoms are
often used to study and model light propagation. However, existing skin phantoms
overlook the important effect of surface roughness on light propagation patterns.
Objectives: (1) To present the design and construction of durable and rough skin
phantoms that can be used to study the propagation of polarized and coherent light.
(2) To validate the surface roughness and the internal optical properties of the
phantoms, and to compare these to those reported for normal skin.
Methods: (1) Solid silicone skin phantoms were constructed using silica microspheres as the scattering particles, and the surface roughness created by curing the
phantoms over standardized roughness metal plates. (2) Surface roughness of these
phantoms was measured using optical profilometry, and their attenuation coefficients were measured using the unscattered transmission (ballistic photons)
approach and compared to those from literature known for normal skin.
Evaluation of curcumin nanoparticles as a potential therapeutic for
wounds
Aimee Krausz, Albert Einstein College of Medicine, Bronx, NY, United States;
Adam Friedman, MD, Albert Einstein College of Medicine, Bronx, NY, United
States; Brandon Adler, Albert Einstein College of Medicine, Bronx, NY, United
States; Breanne Mordorski, Albert Einstein College of Medicine, Bronx, NY,
United States; Joshua Nosanchuk, MD, Albert Einstein College of Medicine,
Bronx, NY, United States; Mahantesh Navati, PhD, Albert Einstein College of
Medicine, Bronx, NY, United States
Results: (1) Our phantoms reliably reproduced the desired surface roughness values
within the range of normal human skin (reported literature values range between
15-50m), with 10% or less variability. (2) The measured bulk optical scattering
properties of the phantoms fall within the calculated theoretical range and are in
agreement with previously reported values (56.7-189.7 cm-1), with measured attenuation coefficients of 62 6 4 cm-1 and 89 6 5 cm-1 for phantoms #1 and #2 respectively.
Conclusion: We created skin phantoms with surface roughness and bulk optical
properties that simulate human skin. These phantoms would be suitable for
modeling lighteskin interactions involving both surface and volume scattering of
human skin. To our knowledge, this is the first report of durable tissue phantom
fabrication where both surface roughness and optical properties are controllably
produced.
Curcumin, the nontoxic, bioactive compound found in turmeric, has demonstrated
broad antimicrobial, antiinflammatory, and wound healing activity, making it an
ideal agent for the treatment of of broad range of dermatologic diseases. Despite its
therapeutic potential and high safety profile, topical administration in the clinical
setting has been precluded by poor skin penetration because of low aqueous
solubility, bioavailability, and a cosmetically unpleasing bright yellow color. To
overcome these limitations, a composite hydrogel/glass nanoparticle platform was
used to effectively encapsulate curcumin and subsequently allow for controlled and
sustained release. Curcumin nanoparticle (C-np) were characterized using dynamic
light scattering and spectrophotometry. In vitro, C-np were found to have a
significant dose dependent impact on clinical isolates of methicillin-resistant
Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, and
Psuedomonas aeruginosa growth based on Bioscreen C as compared to untreated
controls. Complete inhibition of bacterial growth was achieved for all concentrations of the C-np tested for at least four hours, with 100% inhibition maintained for
24 hours with a maximum dose of 20 mg/ml (steady state 1 g curcumin release). To
assess impact on wound healing, C-np were used in a murine full thickness thermal
burn model. Every other day treatment with C-np resulted in clinically accelerated
wound closure as compared to untreated and silver sulfadiazine controls. Histologic
sectioning of C-np treated wounds on day 11 demonstrated a well re-epithelialized
epidermis and maturing dermis with enhanced collagen deposition based on
trichome mason staining and increased CD34+ vessels in the wound bed as
compared to controls. Because of the ease of delivery and formulation, nanoparticle
technology is poised as an innovative method of translating the antimicrobial and
wound healing properties of curcumin to the clinical arena for the broad treatment
of uncomplicated and infected wounds.
Commercial support: None identified.
Commercial support: None identified.
P8656
Effect of pseudoceramide moisturizer on barrier integrity and treatment
of winter xerosis
Lisa S Adams, Kao USA, Inc, Cincinnati, OH, United States; Andrew DiMuzio, Kao
USA, Inc, Cincinnati, OH, United States; Sirlei Waterhouse, Kao USA, Cincinnati,
OH, United States; Ward Billhimer, MS, Kao USA, Inc, Cincinnati, OH, United
States
Winter weather can have a significant adverse impact on skin and its barrier
properties. Particularly, lipid composition and structure within the stratum corneum
can become disrupted causing extreme discomfort from symptoms like tightness,
flakiness, itching, cracking, irritation, and redness. These symptoms can significantly impact how an individual feels both from a sensory perspective as well as
overall well being and emotional state, suggesting a strong relationship between
moisture barrier, lipid composition and quality of life (QoL). This study’s objective
was to understand the issues women experience with dry skin over a 12-week
period during the winter months in Minnesota, gather key physiologic measurements of the stratum corneum and assess changes in skin dryness over the course of
treatment. The study compared changes in stratum corneum lipid composition
through the use of a pseudoceramide containing moisturizer relative to a group
following their normal habits and practices. Twenty-eight women participated in
this study. The treatment group consisted of 18 subjects using the test lotion at least
4 times per week throughout the test period. The normal habits and practices group
consisted of 10 subjects after their normal skin care regimen with their regular
moisturizing products. All subjects had a minimum baseline dryness score of 2.5 on a
4-point scale. Skin condition of the hands and lower legs was monitored throughout
the study via barrier function (TEWL), hydration (capacitance), QoL (Skindex 16),
expert grading of redness and visual dryness, and subject self-assessment of stinging,
burning, itching, redness, dryness and overall skin condition. questionnaire.
Visioscan imaging captured surface structure; while desquamation was monitored
with Corneofix F20 sampling and imaging. Daily use of the pseudoceramide
moisturizer provided significant hydration and barrier protection for the hands
and legs throughout out the winter season vs. baseline. Subjects using the
pseudoceramide moisturizer perceived significant improvement in their skin
symptoms over the 12-week period versus the normal habits group, specifically
for skin itching, redness, dryness, and overall skin condition and QoL. The percent
improvement in skin hydration and skin barrier of the legs was significantly greater
versus the normal habits group. In addition, the rate of desquamation was
significantly impacted with the use of the pseudoceramide moisturizer versus the
normal habits group.
Commercial support: None identified.
P8035
Evaluation of the antibiotic properties of glutathione
Aimee Krausz, Albert Einstein College of Medicine, Bronx, NY, United States;
Adam Friedman, MD, Albert Einstein College of Medicine, Bronx, NY, United
States; David Schairer, MD, Albert Einstein College of Medicine, Bronx, NY,
United States; Joshua Nosanchuk, MD, Albert Einstein College of Medicine,
Bronx, NY, United States
Skin and soft tissue infections (SSTIs) are growing in prevalence in both the
outpatient and inpatient settings and are some of the most common diseases seen by
dermatologists, who are often the first point of care for these patients. Microbial
resistance to antibiotics continues to rise as more virulent strains evolve, and strains
predominantly found in the hospital setting are now being seen in the community.
Therefore, innovative approaches to combat this trend are needed. Glutathione
(GSH) is a well described and established antioxidant. It participates in detoxification of xenobiotics, regulation of cellular growth, modulation of immune response,
and maintenance of the thiol status of proteins and cellular cysteine levels. GSH is
also known to have a regulatory effect on immune cells and even inherent
antibacterial properties have been reported. To this end, the value of GSH as an
antibiotic was evaluated by growing methicillin resistant Staphylococcus aureus,
Escherichia coli, Klebsiella pneumoniae, and Psuedomonas aeruginosa strains
isolated from human skin and soft tissue infection in the presence of GSH. At a
physiologic concentration of 10 mM, GSH had no effect on bacterial growth. At
concentrations above 50 mM, which created acidic conditions (pH \ 4), bacterial
growth was completely inhibited. When adjusted to physiologic pH, GSH exhibited
a bacteriostatic effect in a concentration-dependent manner. In addition, the
cytotoxicity of GSH was evaluated in a murine cell line and was nontoxic to murine
macrophages, even at the highest concentration tested (160 mM). These results
suggest the potential utility of GSH for the prevention and/or as adjunctive treatment
of skin infections, most significantly in disease states associated with GSH deficiency.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB31
P8166
P8404
Expression of a vitamin transporter gene SLC5A6 is up-regulated in the
epidermis during the early stages of barrier repair and during barrier
formation in vitro
Robert Binder, PhD, Procter & Gamble, Mason, OH, United States; Charles
Bascom, PhD, Procter & Gamble, Mason, OH, United States; Kevin Mills, PhD,
Procter & Gamble, Mason, OH, United States; Michael Robinson, PhD, Procter &
Gamble, Mason, OH, United States; Robert Isfort, PhD, Procter & Gamble, Mason,
OH, United States; Teresa DiColandrea, PhD, Procter & Gamble, Bason, OH,
United States
Inter- and intrapersonal changes in the skin microbiome from infancy to
adulthood
Kimberly Capone, PhD, Johnson & Johnson Consumer Companies, Inc, Skillman,
NJ, United States; Catherine Mack Correa, Johnson & Johnson Consumer
Companies, Inc, Skillman, NJ, United States; Frank Kirchner, MS, Johnson &
Johnson Consumer Companies, Inc, Skillman, NJ, United States; Georgios
Stamatas, PhD, Johnson & Johnson Consumer France, Issy-les-Moulineaux,
France; Janeta Nikolovski, PhD, Johnson & Johnson Consumer Companies, Inc,
Skillman, NJ, United States; Nikoleta Batchvarova, PhD, Johnson & Johnson
Consumer Companies, Inc, Skillman, NJ, United States; Stephen Cox, PhD,
Research and Testing Laboratories, LLC, Lubbock, TX, United States
We have conducted 2 gene expression profiling studies to identify processes and
pathways associated with epidermal barrier homeostasis. In the first study, 3 wellseparated sites on the backs of male and female subjects were tape stripped to the
glistening layer (indicating complete stratum corneum removal), and then full
thickness biopsies were taken at 2, 6, and 30 hr to follow global gene expression
during the early stages of barrier repair. Untreated biopsy sites served as controls.
The epidermis was chemically separated from the dermis and RNA was isolated from
the epidermis for microarray analysis. In the second study, we used reconstituted
epidermal cultures in which a stratified epithelium and mature barrier were induced
by air exposure. Cultures were sampled at multiple time points during barrier
maturation for gene expression profiling. Bioinformatic analysis revealed that the
gene coding for a vitamin transporter, solute carrier family 5 (sodium-dependent
vitamin transporter), member 6 (SLC5A6), was significantly up-regulated about
2-fold at 6 and 30 hr after barrier disruption in both male and female subjects and at
multiple time points during barrier formation and maintenance in the in vitro model.
SLC5A6 transports pantothenate, biotin and lipoate in the presence of sodium.
Pantothenate (vitamin B5) is an essential nutrient and precursor for the synthesis of
CoA, which is a cofactor in more than 100 reactions in intermediary metabolism
including the tricarboxylic acid cycle and fatty acid metabolic pathways. The rate
limiting step in CoA synthesis is catalyzed by the pantothenate kinase (PANK) family
consisting of 4 genes. PANK family members showed a mixed pattern of gene
expression in skin after barrier disruption, with PANK1 and PANK4 down-regulated
6 hr after tape stripping and PANK2 and PANK3 modestly up-regulated at that time.
By 30 hr expression of all PANK family members was nearer to control levels.
Similarly, there was a mixed pattern of expression for these genes in epidermal
equivalent cultures during barrier formation. In contrast, the strong and continuous
up-regulation of SLC5A6 during the early response to barrier disruption and during
barrier formation should provide higher levels of pantothenate for CoA synthesis.
These results provide evidence of the importance of vitamins including pantothenate in barrier health and repair, and support the beneficial effects of panthenol
(pro-vitamin B5) in skin care products.
Sponsored 100% by Procter & Gamble. All authors are Procter & Gamble
employees.
Background: Recent work has demonstrated the intrapersonal and interpersonal
differences in the populations of bacteria living on the skin (microbiome) from
various body sites in adults. However, little is known about how the skin
microbiome evolves over time in healthy subjects with respect to body site and
age.The aim of this study was to investigate changes in the skin microbiome from 3
weeks of age to adulthood.
Methods: Skin microflora samples were obtained from the forearm, anticubital fossa,
forehead, and cheek of 31 infants, 23 toddlers, 55 six to twelve year olds, and 23
adults. Genomic DNA was extracted and 16s rDNA was amplified by PCR and
analyzed using a bacterial tag-encoded FLX-titanium amplicon pyrosequencing
approach.
Results: Significant variation in microbiome diversity based on skin site and age was
observed. More than half of the bacterial sequences obtained from infants and
children were either Streptococcus, Staphylococcus, Propionibacterium, Prevotella,
or Corynebacterium. On adult skin, Propionibacterium, Staphylococcus, and
Streptococcus comprised more than 60% of the total skin microbiome. Analysis of
intrapersonal changes revealed that the presence of Streptococcus in infancy was
maintained in toddlerhood, where it represented more than 20% of the skin
microbiome. Children (6-12 years) showed a reduction in the abundance of
Streptococcus. Over time, we observed a continuous, gradual shift in the most
dominant members of the skin microbiome from 3 weeks to adulthood with
Streptococcus species becoming less dominant as Propionibacterium species
increased. We also observed greater diversity in the skin microbiome of infants and
children as compared with adults.
Conclusions: Understanding the dynamic nature of the skin microflora residing on
infants and children may help to elucidate the microbial interdependencies required
to develop and maintain normal, healthy skin, as well as provide insight into skin
pathophysiology.
Supported 100% by Johnson & Johnson Consumer Companies, Inc.
P8697
Impact of advanced petrolatum-depositing body wash on stratum
corneum barrier function and a healthy skin appearance: Skin biomarker
measures
Karl Wei, PhD, The Procter & Gamble Company, Cincinnati, OH, United States;
Ching Stella, PhD, The Procter & Gamble Company, Mason, OH, United States;
Jesse Krailer, PhD, The Procter & Gamble Company, Cincinnati, OH, United
States; Ken Wehmeyer, PhD, The Procter & Gamble Company, Mason, OH,
United States; Mary Johnson, PhD, The Procter & Gamble Company, Cincinnati,
OH, United States; Russell Spruell, PhD, The Procter & Gamble Company,
Cincinnati, OH, United States
Background: The introduction of moisturizing body wash products is one of the
most significant changes to affect the personal cleansing market. A key factor
contributing to the popularity of these products is that advanced body wash
technologies can be designed to offer significant skin care benefits over even the
mildest bar soap products available commercially today. The recent advances of
‘‘omics’’ technologies such as genomics and proteomics have enabled the objective
molecular assessment of improved stratum corneum barrier function and a healthy
skin appearance following the regular use of an advanced petrolatum-depositing
body wash.
Objective: To determine the impact of an advanced petrolatum-depositing body
wash on stratum corneum barrier function and a healthy skin appearance.
Methods: Standard leg controlled-application test (LCAT) methodology was used.
Treatment was conducted over a 3-week period during the winter season; women
with dry leg skin had their legs washed once daily with randomly assigned body
wash products using water alone treatment as control. Common skin measures were
taken, including expert dryness grading, and assessment of hydration and barrier
function via Corneometer and TEWL. 10 successive D-squame tapes were taken
from unique areas within each treatment site at baseline and at the end of each
treatment week. The strips were then analyzed for biomarkers (IL-1alpha, IL-1ra,
Keratin 1, 10, 11, involucrin, total proteins, and NMFs).
Results: Results indicate that an advanced petrolatum-depositing body wash
delivered significant improvements in standard moisturization measures (dryness
grades, hydration, and TEWL) vs. an alternative technology based on glycinate
surfactant and soybean oil emollient. The advanced petrolatum-depositing body
wash was also shown to significantly improve skin biomarkers (NMFs, barrier
integrity markers, and cytokines) vs. the alternative technology. Taken together, a set
of skin biomarkers have been developed to provide objective, non-invasive, and
consistent measures of stratum corneum barrier function and a healthy skin
appearance for guiding the development of superior body wash formulations.
Supported by The Procter & Gamble Company.
AB32
P8714
Optimum conditions of iontophoresis and electroporation in the
transdermal drug delivery in aesthetic dermatology
Makio Akimoto, PhD, Tokyo University of Technology, Hachioji-city, Tokyo,
Japan; Kazuhisa Maeda, PhD, Tokyo University of Technology, Hachioji-city,
Tokyo, Japan; Mieko Hata, MD, PhD, Takano Medical Clinic, Katsushika-ku,
Tokyo, Japan; Samuel Bohman, PhD, JMEC Co, Ltd, Bunkyo-ku, Tokyo, Japan;
Shinya Nakano, PhD, JMEC Co, Ltd, Bunkyo-ku, Tokyo, Japan; Tokuya Omi, MD,
PhD, Queen’s Square Medical Center, Yokohama, Japan; Yuichi Hayatsu, PhD,
JMEC Co, Ltd, Bunkyo-ku, Tokyo, Japan
Background: Iontophoresis and electroporation is percutaneous absorption method
of the drug using electrical energy. Since the transfection efficiency varies depending on molecular weight and ionic polarity of the drug, the optimum condition
setting is necessary. The objective of this study was investigated the optimal
conditions for the introduction percutaneous absorption enhancer method using
electrical energy.
Methods: The drug was used for introduction of L-hydroxyproline, L-carnosine and
hyaluronic acid varies depending on pH. Pig skins were used as permeation barriers
in the in vitro study. For the in vitro permeation experiments under iontophoresis,
the current density was set at 1mA. Attach the excised skin vertical diffusion cell, we
performed iontophoresis for 30 minutes, then added 400L drug solution by placing
the gauze over the skin permeation test. Delivery conditions were experiments on
absorption promoting effect in positive and negative introducing introduction when
changing from 5 to 9 pH. The effects of waveform and frequency on the skin barrier
function were examined. Electroporation using a one-shot pulse of voltage 60V,
pulse width of 0.5ms.
Results: The experiment was carried out for the introduction efficiency in
introducing negative and positive introduced. As a result, the permeability increased
with the introduction time. The cumulative amount of drugs through skin by
iontophoresis at 30 min is higher than that by passive diffusion, indicating that the
contribution of electrophoretic drift enhanced by iontophoresis was significant for
L-hydroxyproline and carnosine. On the other hand, in the case of hyaluronic acid,
alone iontophoresis is insufficient, by combination with electroporation, high
effects was obtained.
Conclusion: Iontophoresis was effective for penetration into the skin of the drug in
dermatology was revealed. High effects can be obtained by the combined use of
electroporation and iontophoresis if substances of high molecular weight.
Optimization of electrical conditions of iontophoresis in facial equipment was
found to be an important factor.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8689
P8409
Seasonal effect on stratum corneum barrier function and healthy
appearance—Skin biomarker measures
Karl Wei, PhD, The Procter & Gamble Company, Cincinnati, OH, United States;
Ching Stella, PhD, The Procter & Gamble Company, Mason, OH, United States;
Jeremy Christman, PhD, The Procter & Gamble Company, Cincinnati, OH, United
States; Ken Wehmeyer, PhD, The Procter & Gamble Company, Mason, OH,
United States; Mary Johnson, PhD, The Procter & Gamble Company, Cincinnati,
OH, United States; Russell Spruell, PhD, The Procter & Gamble Company,
Cincinnati, OH, United States
Stem cell applications in dermatology
Gonzalo Blasco Morente, PhD, Virgen de las Nieves Universitary Hospital,
Granada, Spain; Carmen Martınez Peinado, PhD, Virgen de las Nieves
Universitary Hospital, Granada, Spain; Cristina Garrido Colmenero, PhD,
Virgen de las Nieves Universitary Hospital, Granada, Spain; Elena Marıa
Jimenez Gonzalez, PhD, Virgen de las Nieves Universitary Hospital, Granada,
Spain; Eliseo Martınez Garcıa, PhD, Virgen de las Nieves Universitary Hospital,
Granada, Spain; Jes
us Tercedor Sanchez, MD, Virgen de las Nieves Universitary
Hospital, Granada, Spain; Salvador Arias Santiago, PhD, Virgen de las Nieves
Universitary Hospital, Granada, Spain
Background: Dry skin is a very common skin disorder that is reflected by reduced
stratum corneum hydration, increased transepidermal water loss (TEWL), and a loss
of skin elasticity. It has been known that dry skin is more frequent in winter/cold/dry
seasons and may be worsen upon repeated usage of non-lipid containing personal
cleansing products. The recent advances of ‘‘omics’’ technologies such as genomics
and proteomics enable a molecular understanding of stratum corneum barrier
function and a healthy appearance.
Objective: To develop a set of molecular measures (skin biomarkers) of stratum
corneum barrier function and determine the skin biomarker profiles of dry skin
during the winter season and healthy looking skin during the summer season.
Method: Healthy females from 18 to 65 were recruited for the study during the
winter season. Subjects were given a commercial synthetic cleansing bar to use at
home for 7 days as prewash. At the end of the prewash, the skin conditions of the
panelists’ legs were evaluated by a qualified grader and instrumental measures for
hydration and barrier function (CCorneometer and TEWL). The minimum dryness
to qualify for this study was grade two. A total of 10 successive D-Squames tapes
were taken from the leg area and analyzed for skin biomarkers (IL-1a, IL-1ra, keratin
1, 10, 11, involucrin, total proteins, and NMFs). The same panelists returned during
the summer. After going through 7-day prewash, the panelists’ leg conditions were
reassessed by visual grading, instrumental measures, and skin biomarkers. A t test
was performed to determine statistical significance of skin conditions and skin
biomarker measures during the summer and winter seasons.
Results: Consistent with literature findings, the skin barrier function was significantly improved in the summer vs. winter as reflected in reduced TEWL, higher
hydration and lower dryness evaluations. This study revealed that there were
significant differences in a number of skin biomarkers between summer and winter
seasons. Specifically, the stratum corneum had significantly higher level of NMF
(pyrolidone carboxylic acid) and differentiation markers (keratins 1,10, and 11), and
lower levels of inflammatory cytokines (ratio of IL-1ra/IL-1a) during the summer vs.
winter. In conclusion, skin biomarkers provide objective and consistent measures of
stratum corneum barrier function and a healthy skin appearance.
Introduction: Thorough knowledge of stem cells (SC) and their sources is enabling
the development of multiple studies about treatment in different dermatologic
pathologies. SC renew themselves through symmetrical divisions and differentiate
into specialized cells, such as epidermal keratinocytes and dermal fibroblasts. SC can
be embryonic if derived from an embryo or somatic if derived from a postembryonic
tissue. The ethical and practical considerations of using embryonic SC are causing
the search for alternative sources such as induced pluripotent SC (iPSC) or the
recent discovery of human cell cloning.
Methods: We present a review of the literature from 2009 to 2013 using Pubmed and
Medline on the profits of SC in the treatment of dermatologic pathologies.
Results: SC can be modified genetically to treat genodermatosis, used to make tissue
(skin) by tissue engineering, used for its immunomodulatory functions or use
culture media in which they have been cultivated as elements of skin barrier repair.
We also described the potential utility of iPSC in creating disease models to
investigate cell behavior and response to treatment. New studies show the potential
usefulness of SC in the treatment of diseases such as xeroderma pigmentosum,
ictiocitosis congenital, epidermolysis bullosa, pseudoxanthoma elasticum, congenital erythropoietic porphyria, alopecia, vitiligo, improvement and repair skin,
systemic immune-mediated dermatoses and aesthetic medicine.
Discussion: The future is bright and there are increasingly more SC utilities in
dermatology. Although the use of SC can assume the cure for many diseases its use
should be cautious and controlled. The main problem that arises is the tumorigenicity of the CM, as the formation of teratomas, which should be eliminated or
reduced in order to be used in clinical practice, properly selected progenitor cells or
adding genes of suicide or toxic agents. Other problems include the possibility of
graft rejection and the ethical and moral objections, something avoidable using
autologous iPSCs.
Commercial support: None identified.
Supported by The Procter & Gamble Company.
P8061
S-nitroso-N-acetylcysteine nanoparticles: An innovative nitrosating agent
for the treatment of dermatologic disease
Brandon Adler, Albert Einstein College of Medicine, Bronx, NY, United States;
Adam Friedman, MD, Albert Einstein College of Medicine, Bronx, NY, United
States; Jason Chouake, MD, Albert Einstein College of Medicine, Bronx, NY,
United States; Parimala Nacharaju, PhD, Albert Einstein College of Medicine,
Bronx, NY, United States; Pedro Cabrales, PhD, University of California, San
Diego, La Jolla, CA, United States
The development of nitric oxide (NO)ebased therapeutics has grown tremendously
because of its well-established and diverse biologic functions, ranging from
vasoactivity to antimicrobial action to modulation of wound healing. In line with
this surge, the use of S-nitrosothiol (RSNO) therapeutics is becoming apparent, as
they can both serve as more stable sources/reservoirs of NO as well as function as
S-nitrosating agents. It is in fact this S-nitrosation of protein thiols through which NO
regulates many physiological processes. An innovative S-nitroso-N-acetylcysteine
encapsulated hydrogel-based nanoparticle platform (NAC-SNO-np) is presented.
NAC-SNO-np was found to efficiently generate nitrosoglutathione from glutathione
for over 24 hours, demonstrating its effective nitrosating potential. In vitro,
NAC-SNO-np demonstrated a significant bacteriostatic and bactericidal impact on
clinical isolates of multidrug-resistant Staphylococcus aureus, Streptococcus
pyogenes, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia
coli, as well as Propionibacterium acnes, based on real-time growth curves,
modified antimicrobial prospecting technique, and colony forming unit assays.
Fibroblast scratch assays were used to evaluate NAC-SNO-np’s potential as a wound
healing adjuvant, demonstrating accelerated wound closure as compared to
controls (73.86% vs. 26.51% closure respectively by 72 hours). To examine their
potential impact on vascular physiology, intravenous infusion of the NAC-SNO-np in
Syrian hamsters was undertaken and resulted in a sustained decrease in mean
arterial pressure and increase in vessel diameter over three hours as compared to
baseline and control particles. Serum chemistries after infusion demonstrated no
toxicity in any groups. These findings suggest that NAC-SNO-np could potentially be
useful for vasoocclusive/spastic dermatologic conditions, given their ability to
maintain a vasodilatory response over time. Together, these data suggest that the
NAC-SNO-np represents a novel means to study the biologic effects of nitrosothiols
and effectively capitalize on their therapeutic potential.
Commercial support: None identified.
P8038
The role of soluble adenylyl cyclase in RAF regulation
Caren Waintraub, Weill Cornell Medical College, New York, NY, United States;
Archana Vishwanath, Weill Cornell Medical College, New York, NY, United
States; Jonathan Zippin, MD, PhD, Weill Cornell Medical College, New York, NY,
United States
The mitogen activated protein kinase (MAPK) cascade is a key regulator of cellular
growth. Cancer causing mutations frequently occur in proteins of this pathway.
Therefore, much effort has been focused on understanding how this pathway is
regulated. Cyclic adenosine monophosphate (cAMP) is one of the oldest signaling
molecules and is capable of activating protein kinases, small G protein exchange
proteins, and ion channels. Furthermore, cAMP is known to regulate multiple
members of the RAF family in distinct ways. In mammalian cells, there are three RAF
proteins C-RAF (RAF-1), B-RAF, and A-RAF. Previous research has shown that cAMP
elevation leads to activation of B-RAF via activation of the exchange protein activated
by cAMP (EPAC) whereas cAMP leads to suppression of C-RAF activity via protein
kinase A (PKA). cAMP regulation of RAF influences MAPK signaling in cancers such
as melanoma. When RAS is mutated in melanoma cells, cAMP signaling is
dysregulated. This signaling disruption is essential for RAF isoform switching from
the normally dominant B-RAF to the C-RAF isoform which is preferred by oncogenic
RAS. Alteration of this cAMP mediated isoform switching has a profound effect on
melanoma growth. There are 10 isoforms of adenylyl cyclase, the enzyme that makes
cAMP, in mammalian cells. We study the soluble adenylyl cyclase (sAC), which is
unique among adenylyl cyclases in that it is not bound to the plasma membrane. We
and others have published that distinct subcellular localization of this protein is
associated with melanoma. We previously reported that in mammalian beta cells,
sAC-dependent cAMP elevation leads to phosphorylation and activation of the
MAPK pathway. We now demonstrate in transformed and cancer cells that sAC can
selectively lead to activation of distinct RAF isoforms. We are establishing whether
the mechanism of sAC-dependent RAF regulation involves posttranslational modification of the RAF protein or is the result of upstream protein regulation.
Understanding the role of sAC in MAPK signaling may lead to the development of
novel biomarkers or therapeutics.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB33
P8519
P7994
TPM: A unique dermal delivery technology
Paul Gavin, PhD, Phosphagenics Ltd, Clayton, Australia; Giacinto Gaetano,
Phosphagenics Ltd, Clayton, Australia; Mahmoud El-Tamimy, PhD,
Phosphagenics Ltd, Clayton, Australia
Vitamin E (a-Tocopherol) is the most common lipid-soluble antioxidant in humans
and a key biological component of all membranes. Direct topical application of aTocopherol to the skin provides benefits including protection against UV-induced
oxidative stress, skin carcinogenesis and erythema. We have previously demonstrated existence of the natural phosphorylated form of vitamin E, a-tocopheryl
phosphate (TP). Additional research has shown that a mixture of TP and di
tocopheryl phosphate (T2P) is able to self assemble into ultradeformable vesicles to
entrap active pharmaceutical ingredients (APIs) and increase their aborption into, or
through, the skin after topical application. This mixture has formed the basis of a
novel delivery technology called TPM.’The mechanism of penetration enhancement
results from the interaction between the TPM structure and skin lipids and
membranes. In vitro permeation experiments were performed comparing the
delivery of a model drug (caffeine) when formulated as TPM vesicles or TPM
dissolved in solution. Both formulations increased delivery versus a control, but the
TPM vesicles increased transdermal delivery of caffeine relative to TPM in solution.
The ability of TP to disturb the normal packing of lipids was examined using
phosphatidylcholine (PC) liposomes and cryo-TEM. Adding TP to PC liposomes
altered their structure, reducing the discrete liposomes to large sheets of flexible
membrane undergoing fusion/fission. It is likely the mechanism by which TPM
increases dermal absorption involves disturbing the normal packing of these lipids
allowing enhanced penetration of APIs. The TPM platform has been tested in early
human clinical trials with tretinoin oxycodone, diclofenac, lidocaine, and oxymorphone. It has also been used to formulate a range of personal care products. In a
dermatopharmacokinetic study utilising tape-stripping, TPM elicited a 3.75-fold
increase in delivery of tretinoin into the strata corneum compared with commercial
comparator without increasing systemic exposure. Despite increased tretinoin
absorption, a repeat insult patch test (RIPT) conducted in 27 subjects showed an
overall reduction in irritation. ’TPM is able to increase the absorption of molecules
into the skin for increased efficacy, while reducing common adverse effects such as
irritation. It has potential to improve delivery of a wide range of molecules for
dermatologic treatment.
A case of Spitz nevus on the perianal area of a child
Dong Yeup Lee, MD, Department of Dermatology, Sanggye Paik Hospital, Seoul,
South Korea; Hyun Su Park, MD, Department of Dermatology, Sanggye Paik
Hospital, Seoul, South Korea; Myoung Shin Kim, MD, Department of
Dermatology, Sanggye Paik Hospital, Seoul, South Korea; Un Ha Lee, MD,
Department of Dermatology, Sanggye Paik Hospital, Seoul, South Korea
Spitz nevus is a variant of melanocytic nevus that is histopathologically composed of
numerous uniform nests of spindle and/or epithelioid cells. Clinically, it is relatively
common in children and usually appears as asymptomatic, dome-shaped, round to
oval, firm nodule with a wide spectrum of colors ranging from translucent to purple,
brown or black. The head and neck are known to be the most common involved
sites, though it may involve any parts of the body. Our patient was a 3-year old male
presented with a 1-year history of erythematous pedunculated papule on the
perianal area. The lesion was asymptomatic and has been gradually enlarged.
Histopathologic examination revealed numerous uniform nests of spindle cells and
epithelioid cells with abundant eosinophilic cytoplasm from dermoepidermal
junction to deep reticular dermis. There was no atypical feature such as mitoses
or pleomorphism. On immunohistochemical staining, nest cells were superficially
positive for HMB-45 and Ki-67. Because the shave excision of his lesion was
accomplished, there have been no new lesions. Little is known about the Spitz nevus
arising from the perianal area, so we report a case of Spitz nevus occurring on the
perianal area, where it rarely occurs.
Commercial support: None identified.
Sponsored 100% by Phosphagenics Ltd.
CLINICAL DERMATOLOGY AND OTHER
CUTANEOUS DISORDERS
P8517
229 consecutive patients at an academic dermatology clinic for oncology
patients: The Yale Oncodermatology Clinic Experience
Lauren Wiznia, Yale University School of Medicine, New Haven, CT, United
States; Jennifer Nam Choi, MD, Yale University School of Medicine, New Haven,
CT, United States
Background: Many oncology patients experience dermatologic toxicities that can
interfere with their cancer treatment regimen.
Objective: The objective was to analyze the clinic’s impact on patients’ oncologic
treatment as well as to study the patient population. In addition, we studied the
average wait time for obtaining an appointment, a measurement often cited as
evidence of a dermatologist workforce shortage, as compared to reported national
averages.
P8440
Conclusion: The statistically significant difference in appointment wait time
between our oncodermatology clinic and national averages is consistent with
providing oncology patients with dermatologic care early in their disease course.
Incidental dermatologic findings are an additional benefit of the clinic, and the
factors that played a role in this regard warrant further study.
A case series review of an unexplained dermopathy, commonly known as
Morgellon’s disease
Deirdre O’Callaghan, MBBCh, Royal London Hospital, London, United Kingdom;
Anthony P. Bewley, Royal London Hospital, London, United Kingdom
Morgellon’s disease is a poorly understood entitiy characterized primarily by a
pattern of dermatologic symptoms where the sufferer experiences recurrent or
persistent rashes or sores and reports the emergence of fibers or solid material from
the skin. Patients also commonly report sensations of crawling, biting, and stinging
and a need to extract these materials from their skin which can result in significant
disfigurement. It is likened by some to the well established condition, delusional
parasitosis, as both groups share similar features. Patients with Morgellon’s disease
refute this suggestion and tend to be incredibily resistant to therapy.
Methods: We performed a retrospective review of our database of patients seen at
the Joint Dermatology and Liasion Psychiatry clinic at the Royal London Hospital
from 2008 to July 2013 with a dermatologic diagnosis of ‘unexplained dermopathy’
or ‘Morgellon’s.’ We collated all epidemiologic and clinical data on these patients.
Results: Eighteen patients were identifed. A striking female predominance was
noted, accounting for 83% of patients. The median age of patients was 56 years
(range, 34- 73). 69% of patients were white, 23% Afrocaribbean, and 8% were of
Asian ethnicity. The median time to be seen from time of referral was 9 months
(range, 3-12). Three patients had a forensic history. Three patients reported drug
taking.The most frequently employed treatment modalities were antipsychotics,
SSRIs, and topical agents in combination with cognitive behavioural therapy or
counselling.
Conclusion: We offer further insight into this unexplained dermopathy, a sometimes
debilitating condition which as yet has no defined diagnostic criteria and only
ancedotal evidence with respect to management.
Commercial support: None identified.
Commercial support: None identified.
Methods: Patients treated at the Yale Oncodermatology Clinic between January 2009
and December 2011 were retrospectively studied. Patient demographics, dermatologic history, and appointment schedules were abstracted through extensive chart
review. Results were analyzed using t tests, logistic regression, and negative binomial
regression.
Results: The mean age at consult was 58.6 years (SE ¼ 0.97; 95% CI, 56.7-60.5). The
mean wait time until offered appointment was 11.54 days, and the mean wait time
until attended appointment was 12.93 days, both of which were statistically
significant as compared to the lowest reported average wait time nationally of 36
days (P \.001). Younger patients had a shorter wait time to attended appointment
(IRR -2.34; P ¼.987). Younger patients (OR 0.986; P ¼.035), patients who received
dermatologic treatment as a result of the clinic appointment (OR 3.03; P ¼.018), and
patients who had a culture done (OR 2.79; P ¼ .023) were all more likely to have
their cancer treatment impacted by their clinic appointment. Interestingly, whether
or not a biopsy was taken was not likely to have an impact on cancer treatment (OR
1.52; P ¼ .282). Several factors were associated with an increased likelihood of an
incidental dermatologic finding: increased wait time until attended appointment
(OR 1.02; P ¼.047), performance of biopsies (OR 5.28; P\.001), use of cultures (OR
2.57; P ¼ .007), and prescription of dermatologic treatments (OR 3.09; P ¼ .018).
Limitations: The study’s limitations include its single institutional nature and the lack
of a comparable nononcodermatologic patient group.
AB34
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8617
P8145
A first case of pachydermoperiostosis associated with acromegaly and
chronic infection hepatitis B virus
Minh Van Hoang, MD, University of Medicine and Pharmacy of Ho Chi Minh City,
Ho Chi Minh, Vietnam; Duc Tan Vo, MD, University of Medicine and Pharmacy of
Ho Chi Minh City, Ho Chi Minh, Vietnam; Khanh Quang Tran, MD, PhD,
University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh,
Vietnam; Ly Thi Nguyen, MD, University of Medicine and Pharmacy of Ho Chi
Minh City, Ho Chi Minh, Vietnam; Phung Kim Thi Ngo, MD, PhD, University of
Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh, Vietnam; Tan Thanh
Nguyen, MD, Quy Hoa National Leprosy Dermatology Hospital, Binh Dinh,
Vietnam
A retrospective review of 22 cases of cutaneous vasculitis
Kun Sen Chen, MBBCh, Glan Clwyd Hospital, Rhyl, United Kingdom; Periasamy
Balasubramaniam, MBBS, MD, Wrexham Maelor Hospital, Wrexham, United
Kingdom
Objectives: To analyze the presentations of patients with cutaneous vasculitis (CV),
the use of urinalysis and skin biopsies, and the effective treatment options for CV.
Pachydermoperiostosis (PDP) or primary hypertropic osteoarthropathy is a rare
syndrome that was first described in 1868 by Friedreich. It is characterized by digital
clubbing, pachydermia, and periostosis. The pathogenesis of the disorder has not
been clarified and few endocrine abnormalities were apparent especially acromegaly. Recently, there are only a few reports about this association and no report
about the association between PDP, acromegaly, and human hepatitis B virus
(HBV).We report a case acromegaly associated with PDP and chronic infection with
HBV. A 28-year-old man presented with clubbing, coarsening of facial features with
thickened and prominent skin folds of the forehead, cheeks and nasolabial fold
(pachydermia) and scalp (cutis versitis gyrata), excessive sweating in both hands and
trunk, seborrhea for the last 3 years. A radiograph revealed thickening cortical bone
of bilateral femurs, tibias and fibulas, some focus subperiosteal new bone formations
at bilateral tibias and fibulas. The diagnosis of acromegaly was suggested in this
patient. An IGF-1 screening test was done with the result of 185 ng/mL (normal
range for sex and age, 35-155 ng/mL). To confirm the diagnosis of acromegaly, then
after we performed an oral glucose tolerance test with 75 g of glucose. The growth
hormone (GH) level at baseline was 0.03 ng/mL while the GH level at 2 hours after
ingestion of glucose was 2.44 ng/mL. A MRI of the pituitary showed a microadenoma
of 3 3 4 mm in diameter. The patient also has chronic infection with HBV caused by
hepatitis B serologic testings show: HBsAg positive, IgM anti-HBc negative, total
(IgM + IgG) anti-HBc positive. AST, ALT, and bilirubin are within the normal range,
quantification of HBV-DNA with Cobas TaqMan: 3.27 3 10 log2 IU/mL. This is the
first case of pachydermoperiostosis associated with acromegaly and chronic
infection with hepatitis B virus.
Commercial support: None identified.
Methods: A retrospective case note review of 22 patients (59% [13/22] female, 41%
[9/22] male; mean age 50.5 years [range, 16-85 years]) with CV from 2 district
general hospitals.
Results: The causes of CV were idiopathic (56% [12/22]), HenocheSchonlein
purpura (HSP, 18% [4/22]), urticarial vasculitis (UV; 18% [4/22]), flucloxacillininduced (1/22) and due to an upper respiratory tract infection (URTI, 1/22). 95%
(21/22) of cases involved the lower limbs (lower legs, 100% [21/21]; thighs, 57%
[12/21]), 50% (11/22) involved the trunk (abdomen, 73% [8/11]; back, 27% [3/11])
and 45% (10/22) involved the upper limbs (forearms, 50% [5/10]; upper arms, 30%
[3/10]). Arthralgia is an extracutaneous feature present in 75% (3/4) of HSP, 36%
(5/14) of cutaneous small-vessel vasculitis (CSVV; idiopathic, flucloxacillin-induced
and due to URTI) and 25% (1/4) of UV. Urinalysis was done in 86% (19/22) of cases,
where 42% (8/19) had abnormal results (hematuria, 100% [8/8]; proteinuria, 63%
[5/8]) suspicious of systemic involvement. Skin biopsy specimens were obtained in
36% (8/22) of cases. Perivascular neutrophilic infiltrate (75% [6/8]) and the presence
of eosinophils (75% [6/8]) were the most common histologic features, followed by
erythrocytes extravasation (50% [4/8]). Effective treatments used in CSVV were oral
prednisolone (43% [6/14]), very potent topical corticosteroids (14% [2/14]) and
nonsteroidal antiinflammatory drugs (14% [2/14]), with 3 cases resolving without
treatment and 1 case unresolved. All cases of HSP were effectively treated with
supportive care, with oral prednisolone required in 1 case. The treatments used in
UV were oral antihistamines (2/4), oral prednisolone (1/4) and topical corticosteroids (1/4), all effective in managing the condition.
Conclusions: About half of the cases with CV were idiopathic. CV most frequently
involves the lower limbs, with arthralgia as a common extracutaneous feature (41%
[9/22]). Urinalysis was missed in 14% (3/22) of cases. Almost half of the urinalysis
done revealed haematuria (HSP, 75% [3/4]; CSVV, 36% [5/14]) that required followup review by nephrologists, highlighting the importance of this bedside investigation during the initial assessment of patients. Oral prednisolone is effective in
adequately managing CV (36% [8/22]) unresponsive to other first-line treatments.
Commercial support: None identified.
P7945
P7706
Adalimumab treatment is associated with pain reduction in patients with
hidradenitis suppurativa, regardless of the presence of depression: Results from a phase II, randomized, placebo-controlled trial
Noah Scheinfeld, MD, Department of Dermatology, Weil Cornell Medical College
Midtown West, New York, NY, United States; Henrique Teixeira, MD, AbbVie Inc,
North Chicago, IL, United States; Martin Okun, MD, AbbVie Inc, North Chicago,
IL, United States; Murali Sundaram, PhD, AbbVie Inc, North Chicago, IL, United
States; Na Cui, MS, AbbVie Inc, North Chicago, IL, United States
Introduction: Hidradenitis suppurativa (HS), also known as acne inversa, is a painful,
chronic, recurrent, inflammatory skin disease, associated with several comorbidities
including depression. Association of pain and depression has been reported. This
post hoc analysis evaluates the relationship of pain and depressive symptoms
experienced by patients with HS from the first 16 weeks of a 52-week trial of
adalimumab (ADA) treatment (NCT00918255).
Methods: A total of 154 patients with moderate to severe HS (HS-Physician’s Global
Assessment ¼ moderate) were randomized 1:1:1 to ADA 40 mg weekly (ew) starting
at Week 4 (after 160 mg at Week 0, 80 mg at Week 2) (n ¼ 51), ADA 40 mg every
other week (eow) starting at Week 1 (after 80 mg at Week 0) (n ¼ 52), or placebo
(pbo) (n ¼ 51). Degree of pain was assessed by Patient’s Global Assessment of skin
pain visual analog scale (VAS; 0-100 scale, higher score signifies worse pain).
Depressive symptoms were assessed by PHQ-9 scale (\10 absent; ¼ 10 present). A
clinically relevant reduction in pain was defined as 30% reduction in VAS score and at
least 10 mm absolute reduction among patients with baseline VAS score ¼ 10. Pain
was assessed at baseline and Week 16 for all patients; patients with missing VAS
scores were counted as nonresponders.
Results: Mean (SD) baseline VAS pain scores were 57.8 (28.51), 53.0 (26.35), and
52.0 (24.51) for ew, eow, and pbo patients, respectively. The percentages of patients
with PHQ-9 scores ¼ 10 were 51.0% ew, 33.3% eow, and 41.2% pbo. Across the 3
treatment arms, mean (SD) baseline VAS pain scores were higher for patients with
baseline PHQ-9 score ¼ 10: 54.3 (26.53) for all patients, 63.9 (23.34) for patients
with PHQ-9 score ¼ 10, and 47.4 (26.66) for patients with PHQ-9 score \10 (P \
.001, PHQ-9 ¼ vs \10). At Week 16, clinically relevant reduction in pain was
observed in 47.9% ew, 34.8% eow, and 27.1% pbo patients who did not have missing
baseline PHQ-9 scores, as well as for patients with baseline PHQ-9 score ¼ 10 (45.8%
ew, 29.4% eow, and 23.8% pbo) and for patients with baseline PHQ-9 score \10
(50.0% ew, 37.9% eow, and 29.6% pbo).
Conclusions: Patients with moderate to severe HS had a high degree of pain and a
high prevalence of depressive symptoms at baseline. Although pain levels were
higher in patients with evidence of depression, ADA therapy was associated with
pain reduction, irrespective of the presence of depressive symptoms.
Sponsored 100% by AbbVie Inc.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB35
P7848
P8515
An unusual differential for nonmelanoma skin cancer on the dorsum of a
hand: Superficial cutaneous actinomycosis
Rhydian Davies, MBBS, Dermatology Department, Swansea, United Kingdom;
Dafydd Roberts, MBBS, Dermatology department, Swansea, United Kingdom
Introduction: Primary actinomycosis is a rare and difficult to recognize identity.
Infection manifests slowly and systemic symptoms are uncommon. Usually
associated with an oral, abdominal or uterine focal nidus, isolated primary infections
are usually as a result of penetrating trauma. The causative bacteria are facultative
intracellular anaerobic parasites that are difficult to culture. The detection of
sulphur granules histologically is pathognomic.
Case report: Our patient was a 78-year-old woman with type 2 diabetes. She was
known to our department having previously had NMSCs treated on her legs. She
presented with a 6-month history of a nonhealing erythematous plaque on the
dorsum of her right hand. She did recall grazing the area on a rusty door lock some 6
months earlier. Incisional biopsy and histology was obtained which showed
inflammatory change. There were no acid-fast bacilli nor fungal elements and
sulphur granules were detected. Subsequent tissue culture was unsuccessful in
detecting a causative organism and negative for actinomycosis cultures. Resolution
of the lesion was achieved with 6 weeks empirical phenoxymethylpenicillin.
Discussion: Actinomycoses was first isolated in 1885 by Israel, hence the name of
the most virulent species in humans, Actinomyces israeli. Before the emergence of
antibiotics, it was once a common clinical diagnosis. Today, outside of the
developing world, primary actinomyces infection are rare. Infection of sites not
related to the oral cavity or abdominal cavity are rarer still. Our case is a rare example
where inoculation of subcutaneous tissue with a suspected actinomyces species has
resulted in a chronic cutaneous infection and localised inflammatory response.
Despite attempts to culture a causative organism, only skin commensal organisms
were grown. Clinical diagnosis of actinomycosis requires a high degree of clinical
suspicion. Tissue cultures can be unhelpful but fortunately resistance to beta lactam
antibiotics is rare.
Commercial support: None identified.
P8384
Anatomy of a skin biopsy: A retrospective analysis of outpatient biopsy
results from 2000 to 2010
Charles Phillips, MD, Brody School of Medicine at East Carolina University,
Greenville, NC, United States; Austin Newsome, MD, Hampton UniversitySkin of
Color Institute, Hampton, VA, United States; Defazio Jennifer, MD, MD, Brody
School of Medicine at East Carolina University, Greenville, NC, United States; Fix
Lindsey, MS, Brody School of Medicine at East Carolina University, Greenville,
NC, United States; Harris Green, MD, Dermatology Assoc-Tallahassee,
Tallahassee, FL, United States; Tracy McLean, MD, Brody School of Medicine at
East Carolina University, Greenville, NC, United States
Conclusions: This study highlights the interest, value and impact of a skincare
product containing Ambophenol, Neurosensine, and La Roche-Posay thermal spring
water formulated in a highly protective packaging in monotherapy or in combination with a therapeutic treatment in the management of patients suffering from
rosacea.
Skin biopsies are frequently used in dermatology for diagnosis of and identification
of malignant conditions. Although biopsies have been around as a standard tool in
skin lesion analysis, little is known about the frequency of biopsies or the resulting
‘‘positive’’ yield. The purpose of this study was to evaluate clinical biopsy results
from 2000 to 2010 to determine the characteristics of biopsy as a means for
diagnosis of suspicious skin lesions. A retrospective analysis was conducted on all
pathology results from skin biopsies performed between 2000 and 2010 in the
Dermatology clinic at East Carolina University. Biopsy samples were taken from a
diverse population of patients seen in an outpatient setting in Greenville, NC. The
assessment of results was further stratified based on the reason for biopsy
(inflammatory versus tumor; concern for a pigmented lesion) and the diagnoses
of either basal cell carcinoma, squamous cell carcinoma, melanoma, ‘‘other
cutaneous malignancy’’ and dysplastic nevus. From a sample size of approximately
67,000 office visits that occurred between 2000 and 2010, 20% of patient
encounters resulted in skin biopsy. Of the biopsies, 87.9% were performed for
suspected malignancy and 12.1% were performed for inflammatory conditions.
Among the skin tumor biopsies, 27.5% were diagnosed as basal cell carcinoma,
19.2% were squamous cell carcinoma, 1.5% were melanoma, and 1% were other
cutaneous malignancies. Of the biopsies to evaluate tumors, 29.5% were performed
to further analyze a pigmented lesion; 5.1% were melanoma. Of the pigmented
lesions, 16% were identified as dysplastic nevi with 45.1% had mild atypia, 18.4%
moderate atypia, 9.9% severe atypia, and 26.6% uncategorized. Analysis of the total
malignancies identified per patient over the 10-year period showed a vast majority of
patient (98.5%) diagnosed with 10 malignancies or less. The remaining 2.5% of
patients that exceeded 10 malignancies varied greatly with 7 patients having more
than 35 skin cancers over the course of the decade. The primary reason for
performing a biopsy is typically to identify or verify suspected malignancy. This
study showed a 50% positive diagnostic rate for biopsies of lesions that were
biopsied to identify skin cancer. A minority of skin biopsies are used to clarify the
nature of a rash.
Commercial support: None identified.
Commercial support: None identified.
P7619
An observational study on the management of rosacea in private practice
Sophie Seite, PhD, La Roche-Posay Dermatologic Laboratories, Asnieres Sur
Seine, France
Objective: This study investigates whether a skincare product containing
Ambophenol, Neurosensine, and La Roche-Posay thermal spring water formulated
in a highly protective packaging can have an impact in the management of rosaceaprone skin subjects as either monotherapy and/or adjunctive therapy.
Methods: During this study, dermatologists practicing in Germany, Slovakia, and
Canada were asked about their management of 614 patients suffering from rosacea
(n ¼ 210, 247 and 157 respectively). A questionnaire, containing information about
patient’s characteristics, severity of the pathology and the prescribed therapy was
completed by dermatologists at baseline and 2 months later.
Results: In monotherapy, there was significant efficacy of the test formula associated
with excellent tolerance. Significant improvement of all the clinical signs and
symptoms of rosacea and a reduction of the skin reactivity to ‘‘trigger factors’’ were
shown as either monotherapy or adjunctive therapy.
AB36
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P7810
P7891
Antiaging potential of resveratrol upon clinical and biomechanical
properties of the skin
Claire Deloche, PhD, L’Or
eal Research & Innovation, Chevilly-Larue, France;
Brigitte Lavaud, PhD, L’Oreal Research & Innovation, Chevilly-Larue, France;
Delphine Compan Zaouati, PhD, L’Oreal Research & Innovation, ChevillyLarue, France; Evelyne Segot-Chicq, PhD, L’Oreal Research & Innovation,
Chevilly-Larue, France; Geraldine Dejean, MMSc, L’Oreal Research &
Innovation, Chevilly-Larue, France; Josette Jacquin, PhD, L’Oreal Research &
Innovation, Chevilly-Larue, France; Julien Laboureau, PhD, L’Oreal Research &
Innovation, Chevilly-Larue, France
Atypical StevenseJohnson syndrome
Miguel Vinas, PhD, Consorci Sanitari del Garraf, Sant Pere de Ribes, Spain; Carme
Diaz, PhD, Consorci Sanitari del Garraf, Sant Pere de Ribes, Spain; Xavier Garcia,
PhD, Consorci Sanitari del Garraf, Sant Pere de Ribes, Spain
Introduction: StevenseJohnson syndrome (SJS) is a systemic condition that is
usually preceded by flu-like symptoms followed by severe mucosal/cutaneous
involvement. SJS is characterized by the development of skin lesions with the
appearance of a target, subsequent skin denudation, and severe necrosis of at least 2
mucosal tissues. The reported precipitating factors of this condition include
therapeutic drugs (penicillin, tetracycline, and NSAIDs) and infections
(Mycoplasma pneumoniae). Recently, various cases of SJS without cutaneous
involvement have been described in children or young adults, secondary to M
pneumoniae infection.
Case report: A 19-year-old man presented symptoms of fever, cough and odynophagia. His general practitioner prescribed ibuprofen and amoxicillin 72 hours after the
onset of symptoms. One week later, he came to the emergency room because of
worsening of his overall condition, with mucositis, conjunctivitis and affected
genital mucosa. He had no skin lesions. A presumptive diagnosis of SSJ without skin
involvement was established. On skin biopsy study, the epidermis showed necrotic
keratinocytes and focal spongiosis, and a perivascular lymphohistiocytic infiltrate
was observed in the superficial and middle dermis. Peripheral blood analysis
disclosed high levels of specific anti-M pneumoniae IgM (21 mU/mL). The patient
was diagnosed with atypical M pneumoniaeeinduced SJS. He was treated with
azithromycin and had a favorable outcome.
Purpose: It is widely accepted that both structures and functions of the skin become
altered by the cumulative effects of chronological aging and environmental factors
such as solar exposures. These lead to skin laxity, wrinkling, skin dryness, etc. The
aim of our clinical research was (i) to assess the skin antiaging potential of
Resveratrol, and (ii) to measure the effects on biomechanical properties of the skin
brought by a skincare product containing a combination of Resveratrol and an
oligoside.
Methods: Three studies were conducted: (1) 1 double blind randomized controlled
study to clinically assess the effects of Resveratrol at 0.25% vs. vehicle on the dorsal
arm of 40 volunteers (45-65 y.o.) following twice daily applications for 3 months. (2)
Two bioinstrumental and clinical studies to evaluate (i) the immediate impact
brought by a skincare product containing Resveratrol (0.25%) and the oligoside (4%)
upon skin firmness in 40 subjects (45-65 y.o) using Dermal torque meter and (ii)
changes in the skin wrinkles brought by the same product to 60 volunteers (45-65
y.o.) following daily applications for 2 months.
Results: In the controlled study, skin density was measured with Densiscore
(evaluation of skin folding grade using a 6 point photographic scale). A more
important score decrease (-0.43) was observed on the arm after 3 months of
treatment with Resveratrol as compared to vehicle (P ¼.032). As compared to our
previously established reference curves, where folding scores overall increased by
0.4-0.7 per decade (from 20 to 70 y.o.) on the same skin site, a decrease by 0.43
appears of a relevant meaning. As for open studies, bioinstrumental and clinical
evaluation showed that (i) skin firmness was significantly improved (P \ .001)
immediately after application of the productand (ii) skin wrinkles were significantly
reduced (P \.05) as early as 1 month later. This later result was confirmed after 2
months of treatment.
Conclusions: It is important to be aware that SSJ may be the cause of intensely
affected mucosal tissues in children or young adults, even though skin lesions may
not be present. We should remember that the etiologic agent in these cases is usually
infection by M pneumoniae, so that specific antibiotic treatment can be promptly
established.
Commercial support: None identified.
Commercial support: None identified.
P8272
P8219
Association between scleroderma and lichen striatus: A case report
Amanda Pedreira Nunes, MD, Hospital Universitario Ant^
onio Pedro, Niter
oi,
Brazil; Enoi Aparecida Guedes Vilar, MD, Hospital Universitario Ant^
onio Pedro,
Niter
oi, Brazil; Luciana Pantale~ao, MD, Hospital Universitario Ant^
onio Pedro,
Niter
oi, Brazil; Maria Luisa Mendonc¸a Barros, MD, Hospital Universitario Ant^
onio
Pedro, Niter
oi, Brazil; Sandra Maria Barbosa Dur~aes, MD, PhD, Hospital
Universitario Ant^
onio Pedro, Niter
oi, Brazil
Introduction: Lichen striatus is a rare, self-limiting lichenoid eruption of unknown
etiology. Although it can appear at any age, it tends to favor children; more than 50%
of cases occur in individuals 5 to 15 years of age. Both sexes are equally afflicted,
although some studies cite a 2- to 3-fold predominance in women. Its most
characteristic feature is the linear arrangement of slightly raised, lichenoid, pink-red
papules. They may coalesce into small plaques and into a continuous or interrupted
linear band. Most commonly the lesions are located on a proximal extremity and less
commonly on the trunk. Scleroderma is a term used to describe a spectrum of
conditions characterized by hardening and/or thickening of the skin and fibrosis of
the tissues involved. It is didactically divided into systemic and localized forms. The
localized form, also known as morphea, distinguished by predominantly cutaneous
involvement, but with the possibility of occasional involvement of underlying
muscles, while the internal organs are usually spared. In this report, we describe a
case in which there is an association between lesions characteristic of scleroderma
and lichen striatus.
Case report: Patient, 15 years old, white, reports that 6 months ago appeared whitish
spots on the abdomen and right leg, which subsequently increased in number and
size, becoming dark and hardened. Also refers whitish lesions on the left calf. On
examination, were observed hypercromic, shiny-surfaced, scleroatrophic plaques in
the abdomen and right thigh, and hypopigmented, shiny-sufaced papules, with welldefined edges, whose size was approximately two inches in the left calf, following
the lines of Blashko. Histopathologic examination of the thigh injury revealed
hyalinized dermis with entrapment of the sweat duct by dense collagen with
thinning attachments. Histopathologic analysis of the lesion in the left calf showed
epidermal atrophy, foci of basal vacuolization, superficial perivascular lymphocytic
infiltration in exocytosis into the deep epidermis.
Benefiterisk trade-off preferences for severe chronic hand eczema
treatments—Experiences of patients with severe chronic hand eczema
A. Brett Hauber, RTI Heath Soultions, Research Triangle Park, NC, United States;
Ateesha F. Mohamed, RTI Heath Solutions, Research Triangle Park, NC, United
States; Juan Marcos Gonzalez, RTI Heath Solutions, Research Triangle Park, NC,
United States; Ole Graff, Stiefel, a GSK Company, Research Triangle Park, NC,
United States; Susan C. Zelt, Stiefel, a GSK Company, Research Triangle Park, NC,
United States
Background: Approximately 10% to 15% of the US population is affected by hand
eczema (HE), and long-term prognosis is poor. A subset (5%-7%) of HE patients
experience severe CHE, which interferes with daily activities. There is an unmet
need for effective treatment options in patients with severe CHE who are refractory
to topical corticosteroids.
Objectives: To report experiences and characteristics of patients with severe CHE
responding to a benefit-risk assessment survey regarding hypothetical CHE
medications.
Methods: Adult patients with a self-reported physician diagnosis of CHE with severe
symptoms limiting normal daily activities and for whom topical agents did not
completely clear CHE signs and symptoms completed a Web-enabled, discretechoice survey in the United States. Each respondent answered a series of 10
treatment-choice questions aimed at assessing experiences of patients with severe
CHE and treatments they used for these symptoms.
Discussion: The lesions present in the abdomen and right leg were suggestive of
scleroderma, which was confirmed by histopathologic report, and the biopsy results
of the papules in the left calf were lichen striatus. Occasionally, there is overlap of
lichen striatus with linear lichen planus and ‘‘blaschkitis,’’ the main differential
diagnoses. However, the emergence of concomitant sclerodermoid injuries and
lichen striatus is rare and poorly described in the literature.
Results: Demographic information was available for 600 patients (predominantly
female; mean age, 43 years; median educational attainment, associate/2-year college
degree). The largest percentage of patients experienced CHE symptoms for 20 years
(27.4%). Most frequently, patients reported current symptoms of dryness and/or
flaking (88.2%), itchiness (87.3%), cracking or tearing of the skin (82.3%), redness
(80.0%), irritation (75.7%), pain (56.8%), and crusty skin (56.3%). Patients reported
being most bothered by cracking or tearing of the skin (32.9%), followed by
itchiness (31.7%) and pain (15.2%). Most patients reported worsening of CHE
symptoms with frequent hand washing and drying (80.2%) and use of soaps,
detergents, cosmetics, or cleaning products (79.5%). Self-management of CHE most
frequently included use of moisturizers (91.5%), rubber gloves for dishwashing or
submerging hands (69.2%), and mild detergents for washing clothes (61.8%). The
majority of patients had previously used topical corticosteroids (93.3%) and
antihistamines (55.0%) to treat their HE. Patients reported a median score of 7.0
on a scale of 0 to 10 for disease interference with daily activities in the past week,
and 81.5% of patients reported feeling embarrassed, 52.0% felt anxious, and 37.3%
avoided social activities due to their HE.’
Conclusions: Patients with severe CHE experience symptoms that interfere with
daily activities and have severe negative impacts on their quality of life.
Commercial support: None identified.
Supported by Stiefel, a GSK Company.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB37
P8136
P8069
Benefiterisk trade-off preferences for severe chronic hand eczema
treatments
A. Brett Hauber, RTI Heath Solutions, Research Triangle Park, NC, United States;
Ateesha F. Mohamed, RTI Health Solutions, Research Triangle Park, NC, United
States; Juan Marcos Gonzalez, RTI Health Soutions, Research Triangle Park, NC,
United States; Ole Graff, Stiefel, a GSK Company, Research Triangle Park, NC,
United States; Susan C. Zelt, Stiefel, a GSK Company, Research Triangle Park, NC,
United States
Background: Hand eczema affects 10% to 15% of the US population. Long-term
prognosis is poor, and 5% to 7% of patients experience severe chronic hand eczema
(CHE) that interferes with daily activities. However, treatments for CHE may be
associated with adverse events (AEs) or may be ineffective, which may dissuade
patients from pursuing or continuing treatment.
Bevacizumab-induced pityriasis rubra pilariselike eruption
Wesley Fletcher, MD, Scott & White Dermatology, Temple, TX, United States;
Katherine Fiala, MD, Scott & White Dermatology, Temple, TX, United States;
Shannon Brown, Texas A&M Health Science Center College of Medicine, Bryan,
TX, United States
Objectives: To quantify patient benefit-risk trade-off preferences for the outcomes
associated with CHE treatments, specifically between efficacy and AEs.
Methods: Adult patients in the US with self-reported physician diagnosis of CHE and
severe symptoms not resolved with topical agents that limited normal daily activities
completed a Web-enabled, discrete-choice survey. Respondents were recruited from
2 sources: Harris Interactive’s (HI’s) online chronic illness panel and the National
Eczema Association’s (NEA’s) member panel. Each respondent answered a series of
10 treatment-choice questions. Each question required evaluating a pair of hypothetical severe CHE medication profiles defined by efficacy (severity of CHE after
treatment), severe headaches during the first month of taking the medication, risk of
permanent vision or hearing problems, risk of permanent bone problems, and risk
of suicidal ideation. Random-parameter logit models were used to explain respondents’ choices regarding medication characteristics and estimate the relative
contribution of each treatment outcome to choice, also known as preference
weights; these were used to determine the mean maximum acceptable risk (MAR) of
each AE for improvements in efficacy.
Results: Final samples consisted of 399 respondents from the HI sample and 200
respondents from the NEA sample. Statistical tests indicated that the 2 samples
could not be pooled due to differences in variance (P \ .05). Improvement in
clearing from 25% to 50% was rated as 1.5 times as important as eliminating a 5% risk
of permanent bone problems in the HI sample and 3.1 times as important in the NEA
sample. The mean MAR for permanent vision problems in exchange for an
improvement in clearing from 25% to 50% was 3.4% (95% CI, 2.1%-4.6%) for the
HI sample and 4.8% (95% CI, 2.3%-7.0%) for the NEA sample.
Conclusions: Efficacy improvements associated with treatment of severe CHE were
rated as more important than elimination of risks of specific AEs.
Pityriasis rubra pilaris (PRP) is a rare inflammatory disorder characterized by
follicular papules on an erythematous base often exhibiting islands of unaffected
skin, follicular plugging, and palmoplantar hyperkeratosis. While vitamin A
deficiency and autoimmune reactions have been hypothesized as possible etiologies
of pityriasis rubra pilaris, PRP-like eruptions secondary to medications are extremely
rare. To the authors’ knowledge, only 3 other cases have been reported. PRP has
never been reported in association with bevacizumab. We present a 70-year-old male
who developed erythroderma, which was both clinically and histologically
consistent with PRP, 10 days after an intravitreal injection of bevacizumab for agerelated macular degeneration. Our patient’s PRP-like eruption responded dramatically to oral corticosteroids, which is rarely helpful for PRP. As immunomodulating
drugs grow in their application in various diseases, recognition of associated
medication complications is helpful in dermatologic practice.
Commercial support: None identified.
Supported by Stiefel, a GSK Company.
P8688
Benign cutaneous Degos disease
Kwei-Lan Liu, MD, Taichung Veterans General Hospital, Taichung, Taiwan;
Chii-Shuenn Yang, MD, Taichung Veterans General Hospital, Taichung, Taiwan;
Jui-Lung Shen, MD, PhD, Taichung Veterans General Hospital, Taichung, Taiwan;
Yi-Ju Chen, MD, PhD, Taichung Veterans General Hospital, Taichung, Taiwan
Degos disease, a rare occlusive vasculopathy, is characterized by pathognomonic
skin eruption with subsequent systemic involvement and skin-limited disease. The
skin lesions usually precede systemic manifestations with gastrointestinal tract and
central nervous system being most commonly affected. Degos disease has been
classified into 2 forms: classical and benign cutaneous with the latter being the less
common form. We reported a case of a 41-year-old woman with a 2-year history of
multiple asymptomatic, pea-sized, atrophic porcelain-white papules with an
erythematous, telangiectatic rim on the trunk and limbs. She had experienced
abdominal fullness and vomiting for 1 year. Histopathology of a skin biopsy
specimen showed epidermal atrophy and wedge-shaped degeneration of collagen
in which obliterative vessels were present. Alcian blue staining demonstrated
abundant mucin deposition outlining the wedge-shaped area. Direct immunofluorescence was negative. The clinicopathologic features were compatible with Degos
disease. Laboratory tests were all within normal limits, including complete blood
cell count, hepatorenal function, urinalysis and immunologic fecal occult blood test,
as well as profiles of lupus erythematosus, systemic sclerosis, rheumatoid arthritis,
dermatomyositis, antiphospholipid syndrome, coagulopathy, and vasculopathy.
Magnetic resonance images of the brain and upper gastrointestinal and small bowel
series showed no abnormalities. Panendoscopy revealed merely reflux esophagitis.
A diagnosis of benign cutaneous Degos disease was made. Under treatment with
aspirin and dipyridamole, the cutaneous lesions healed with atrophic scars. No
intestinal perforation, cerebrovascular accident, or other life-threatening complications attacked during the following 6 months. To date, fewer than 40 cases of benign
cutaneous Degos disease with characteristic histopathology and at least 6 months of
follow-up have been reported. There is no definite clinical, laboratory, or histopathologic indicator to predict the clinical course and to distinguish the classical and
benign cutaneous variants at the time of presentation. The combination of aspirin
and dipyridamole or each alone has shown variable effectiveness, while corticosteroids may worsen skin eruptions and complications. Patients with benign cutaneous
Degos disease may have a fair prognosis with long-term survival, but they require
regular follow-up because of the possibility of future systemic involvement.
Bier spots: A case report
Thaıs Martins Tonso, MD, Hospital E Maternidade Celso Pierro - PUC Campinas,
Campinas, Brazil; Adilson Costa, MD, PhD, Hospital E Maternidade Celso Pierro PUC Campinas, Campinas, Brazil; Aline Siqueira Talarico, MD, Hospital E
Maternidade Celso Pierro - PUC Campinas, Campinas, Brazil; Elisangela
Samartin Pegas Pereira, MD, Hospital E Maternidade Celso Pierro - PUC
Campinas, Campinas, Brazil; Lissa Sabino Matos Matos, MD, Hospital E
Maternidade Celso Pierro - PUC Campinas, Campinas, Brazil; Thaisa Saddi
Tannous, MD, Hospital E Maternidade Celso Pierro - PUC Campinas, Campinas,
Brazil
The objective of this study is to report a case of Bier spots in a female, 14 year-old, of
Chinese descent, with a 2-year history of asymptomatic hypopigmented macules on
her lower limbs. These macules became more evident when the patient remained in
orthostasis, and vanish with the elevation of the limbs, or when a pressure was
applied on the lesion. It showed no change with exposition to thermal variation. The
patient underwent a clinical and laboratory research which led us to the diagnosis of
Bier spots. Bier spots are a benign vascular abnormality and its recognition is
important because of the similarity that it has with other vascular phenomena. Its
incidence is unknown, and believed to be a poorly recognized entity in clinical
practice. Clinically, it manifests as hypochromic macules, small and irregular,
surrounded by erythematous areas in members. These characteristics give the
skin a mottled appearance. The lesions are induced by gravity-dependent positions:
they can be elicited while the individual remains in orthostasis and disappear when
the affected member is raised, or with a hold pressure at the erythematous area that
surrounds it. Patients with Bier spots are usually asymptomatic; cases reported in the
medical literature shows no abnormalities on blood tests or skin biopsies. It is
believed that such abnormality is caused by a venous hyperreactivity, manifesting
itself through vasoconstriction of venules and venous dilation reflex of surrounding
areas. Are considered as trigger, to such a nonmodulated response, the venous stasis,
associated with hypoxia or failure venoarteriolar reflex of the descendants dermal
arterioles, in response to venous filling. Despite showing macroscopic appearance
similar to anemic nevus, Bier spots differs completely in other aspects. Regarding
the treatment of Bier spots, there is 1 report in the literature, and it was
unsuccessful. Because of the asymptomatic character of this condition, associated
with no systemic repercussions, it is concluded that the indication for treatment is
the aesthetic discomfort that brings injury to the patient. The treatment can be tried,
but should be individualized, and it is important to note that, so far, satisfactory
results were not obtained.
Commercial support: None identified.
Commercial support: None identified.
P7536
AB38
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8329
P8614
Botulinum toxin and the posterior rami syndrome: The relief of
dermatomal sensory manisfestations and other painful conditions
Nardo Zaias, MD, Mt Sinai Medical Center, Division of Dermatology, Miami Beach,
FL, United States; Eve Del Rio, MD, PhD, Mt Sinai Medical Center, Division of
Dermatology, Miami Beach, FL, United States; Jamie Herman, PA, Barry
University, Miami Shore, FL, United States; Martin N. Zaiac, MD, Mt Sinai
Medical Center, Division of Dermatology, Miami Beach, FL, United States;
Mercedes Florez-White, MD, Mt Sinai Medical Center, Division of Dermatology,
Miami Beach, FL, United States; Ploypailin Jungcharoensukying, MD, ScD, Mt
Sinai Medical Center, Division of Dermatology, Miami Beach, FL, United States;
Sandra Escovar, MD, Mt Sinai Medical Center, Division of Dermatology, Miami
Beach, FL, United States
Botulinum toxin has been used in cosmetic dermatology to relax dynamic wrinkles,
but not much data has been reported for the relief of dysesthesia. In this study,
patients with pain and other dysesthesia were included. The diagnoses of each
patient is as followed: acute herpes zoster and postherpetic neuralgia, localized
pruritus of unknown origin, painful fingertips, segmental pain from vertebral
abnormalities, and a painful leg ulcer. The severity of the pain was assessed and
graded on 0 to 10 pain score. The corresponding dermatome was identified and the
toxin was injected at the exit point of posterior dorsal rami (approximately 1 cm
laterally from the mid line), including 2 dermatomes above and 2 below. The pain
was assessed and graded by the patient again at 5, 15, and 30 minutes after the
injection. The patients then were followed up at 2 and 4 weeks to reassess the pain.
In this study, we have found that the injection of botulinum toxin relieves pain and
other dysesthesia. The injection should also relieve the other condition that involve
the release of acetylcholine, proinflammatory, and pain mediators from nerves.
Case report: ChurgeStrauss syndrome associated with Well’s syndrome
Minh Van Hoang, MD, University of Medicine and Pharmacy of Ho Chi Minh City,
Ho Chi Minh, Vietnam; Dat Quoc Tran, MD, PhD, University of Medicine and
Pharmacy of Ho Chi Minh City, Ho Chi Minh, Vietnam; Luong Van Tran, MD,
University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh,
Vietnam; Quang Minh Nguyen, MD, Dermatology and Venereology Ha Noi
Hospital, Ha Noi, Vietnam; Tuan Anh Phan, MD, PhD, University of Medicine and
Pharmacy of Ho Chi Minh City, Ho Chi Minh, Vietnam; Vien The Tran, MD,
University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh, Vietnam
ChurgeStrauss syndrome (CSS) is a systemic vasculitis occurring in patients with a
history of asthma. Well’s syndrome (WS) or eosinophilic cellulitis is characterized
clinically by an acute dermatitis resembling cellulitis and histopathologically by
dermal eosinophilic infiltration. However, cases in which they are associated are
extremely unusual. We present a case of CSS associated with WS. A 56-year-old
woman with a history of athsma, hypertension, nasal polyps e sinusitis and
pneumonia 6 months presented with edema, numbness and weakness of her feet.
She felt weakness and reddish edema appeared like a cellulitis of her right foot.
Simultaneously, she found out the appearance of violaceous bullae on the left ankle
and feet. Dermatologic examination found edematous erythematous urticarial
plaques on the interior left ankle, multiple tense hemorrhagic bulla on her feet,
predominantly on the right one and onychomycosis of the left thumb. The distal leg
muscle strength was 3/5 while the others were 5/5. Routine investigation revealed
leukocytosis (17.94 k/uL) with a prominent eosinophilia 40% (7.186 k/uL),
neutrophils 38.2% (6.867 k/uL), CRP 253.43 mg/L, erythrocyte sedimentation rate
40 to 74 mm. Autoimmunologic tests with ANA, anti ds DNA, anti Sm were negative
but positive ANCA. Electromyography suggested inflammatory myopathy and
Axonal Sensory Motor Polyneuropathy. Radiographs revealed paranasal sinusitis.
Histopathology of the skin biopsy specimen from the bullous lesions showing a large
intraepithelial blister with edema in the upper dermis and abundant diffuse
infiltration of eosinofils is seen in some areas, especially in the vicinity of vessels.
The skin biopsy specimen from the erythematous urticarial plaques in the deeper
dermis revealed eosinophil rich necrotizing vasculitis involving small vessels. Some
small vessels has been filled with organizing thrombi. Our patient demonstrated all 6
criteria for CSS of the American College of Rheumatology as asthma, paranasal
sinusitis, peripheral sensory-motor polyneuropathy in the lower extremity, eosinophilia [ 10%, extravascular eosinophils and pulmonary infiltrates. Besides, Well’s
syndrome is a rare inflammatory disorder characterized by cellulitis-like urticarial
erythema with eosinophilic infiltration. Therefore, this is the case of CSS associated
with WS.
Commercial support: None identified.
Commercial support: None identified.
P8596
Bullous fixed drug eruption mimicking StevenseJohnson Syndrome
Yakir Levin, MD, PhD, Boston University Medical Center Department of
Dermatology, Boston, MA, United States; Emmy Graber, MD, Boston University
Medical Center Department of Dermatology, Boston, MA, United States; Lynne
Goldberg, MD, Boston University Medical Center Department of Dermatology,
Boston, MA, United States; Yoon-Soo Cindy Bae-Harboe, MD, Laser and Skin
Surgery Center of New York, New York, NY, United States
Bullous fixed drug eruption (FDE) is a severe form of FDE accounting for 30% of
cases. The generalized bullous form (gbFDE) is rare and is characterized by the
appearance of numerous deep red edematous plaques surmounted by bullae, which
break easily and leave extensive eroded areas. When generalized, a bullous FDE can
mimic StevenseJohnson syndrome/toxic epidermolysis necrolysis (SJS/TEN),
which clinically exhibits extensive necrosis and detachment of the epidermis
symmetrically distributed on the face, upper trunk, and proximal limbs.
Distinguishing between a gbFDE and SJS/TEN can be challenging but is vitally
important, as the latter is thought to portend a poorer prognosis. Both of these
conditions can feature significant epidermal detachment and a positive Nikolsky
sign. Although less likely in bullous FDE than in SJS/TEN, both can cause systemic
symptoms (;25% in gbFDE) and involve mucous membranes (25-66% in gbFDE).
Both exhibit interface dermatitis on histology, although a FDE tends to have deeper
inflammation and a mixture of inflammatory cells. However, in contrast to SJS/TEN,
lesions in bullous FDE usually occur early, within 10 hours of drug intake. In
addition, bullous FDE lesions generally involve the same sites as were affected in
previous episodes, while recurrent lesions in SJS/TEN show no such predilection.
We present a case of a 22-year-old African American man with a recurrent eruption
with mucous membrane involvement after taking a nonsteroidal antiinflammatory
drug . SJS was considered because of the large number of lesions and presence of
mucosal involvement. Importantly, additional history revealed that the patient
developed lesions within hours after taking naproxen, and that approximately 1 year
before this presentation, he had developed a similar eruption with lesions in the
same locations also within hours after taking naproxen. These details were crucial in
distinguishing his eruption from SJS/TEN, avoiding misdiagnosis and unnecessary,
costly therapeutic intervention. This case highlights the distinguishing features
between these clinically similar but prognostically different entities.
Commercial support: None identified.
P8682
Chronic radiation dermatitis resulting from the use of radioactive
phosphorus 32 in the treatment of childhood hemangiomas in Vietnam
Thanh-Nga Tran, MD, PhD, Massachusetts General Hospital, Charlestown, MA,
United States; Martin Mihm, MD, Brigham and Women’s Hospital, Boston, MA,
United States; Minh Hoang, MD, University of Medicine and Pharmacy, HCMC,
Ho Chi Minh City, Vietnam; Richard Rox Anderson, MD, Massachusetts General
Hospital, Boston, MA, United States; Stuart Nelson, MD, PhD, University of
California, Irvine, Irvine, CA, United States; Thuy Phung, MD, PhD, Baylor
College of Medicine, Houston, TX, United States
Radiotherapy, an essential modality in cancer treatment, frequently induces a
fibrotic process in the skin which can lead to increased risk of malignancy, poor
wound healing, pain and limitation of movement, and permanent loss of skin
appendages with hyper/hypopigmentation, decreased sweating and xerosis, posing
significant cosmetic and quality of life issues. Unfortunately, children in developing
countries, especially in Vietnam, are still being treated with radioactive phosphorus
P32 for their benign vascular tumors, such as hemangiomas and port-wine stains.
During our volunteer work in Vietnam in the past 5 years, we encountered many
patients with severe radiation dermatitis, to the degree unseen here in the United
States. We would like to report on the characterization of the dermatitis in these
patients and report on our activities in changing such practice and the potential
treatment for these patients.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB39
P7696
P8284
Clinical perspectives of mastocytosis: A patient survey
Cathryn Sibbald, MD, University of Toronto, Toronto, Canada; Afsaneh Alavi, MD,
Women’s College Hospital, Toronto, Canada; Carrie D’Arville, Former President,
Mastocytosis Society of Canada, Toronto, Canada; R Gary Sibbald, MD, University
of Toronto, Toronto, Canada
Concomitant fibrosing disorders in childhood
Kazeem Salako, MBBS, Birmingham Children Hospital, Birmingham, United
Kingdom; Malobi Ogboli, MBBS, Birmingham Children Hospital, Birmingham,
United Kingdom
Childhood lichen sclerosus (LiS) is a rare (probably undiagnosed) inflammatory skin
disorder of uncertain clinical course. It may be complicated by vulva architectural
changes of varying clinical depictions. We present a 13-year-old girl who attended
our clinic with whitish-pale skin color changes involving both the eye lids, left neck,
both flanks and right hip of several months duration. These changes were
completely asymptomatic. There was a family history of type 2 DM and
Sarcoidosis in dad older brother aged 15, respectively. Examination revealed
depigmented skin changes on both eye lids and left neck in keeping with vitiligo;
there were hypopigmented, shiny and wrinkling patches noted on both flanks,
medial aspect of the right knee, right hip and vulva opening, raising a suspicion of
lichen sclerosus. The perianal area was normal. Histology of the trunkal lesion
revealed subepidermal oedema, homogenization of the collagen and sclerotic deep
dermis which are in keeping with lichen sclerosus. Also there was hypocellular
compacted collagen in the reticular dermis with periadnexal and perivascular
lymphocytic infiltrates and occasional eosinophils. While the propensity for
malignant transformation in Lichen sclerosus is possible, there has not been any
long term study to definitely establish the connection. Localised scleroderma LoS
(morphea) is a chronic inflammatory skin condition associated with increased
collagen and extracellular matrix in the dermis. The etiology is unknown. The
coexistence of LiS with localised scleroderma LoS (morphea) in adult is well known
in literatures but very rarely documented in children. This is more evident in a recent
retrospective analysis of 472 patients from Germany, 91 of who were children. Only
1 child out of 27 patients had concomitant LiS and LoS. In coexisting disease,
histologic studies using lectin staining have been used to delineate the 2 conditions.
While the mechanism of the disease process has not been elucidated, it is likely that
the lesions represent a spectrum which may reflect closely related pathologic/etiologic processes in these 2 diseases. It is imperative to examine the skin of patients
with localised scleroderma for LiS. The prognosis is uncertain; hence, long-term
follow-up is recommended.
Background: Mastocytosis is an uncommon disease often referred to dermatologists,
with both cutaneous forms and systemic forms with frequent skin involvement.
Given its nonspecific presentation and low prevalence, diagnosis can be delayed
from 2 to 10 years. Most of the current literature focuses on the presentation and
diagnosis, with limited published data on the significant impact of this disease on
quality of life. As patients play a key role in the success of treatment plans, assessing
their experiences would help guide clinicians for optimal management.
Methods: An online survey was sent to members of the Mastocytosis Society of
Canada, a Canadian mastocytosis support group. The survey consisted of 36
questions about mastocytosis including patient quality of life, triggers, anxieties,
patients’ preferences for prevention, treatment, and information.
Results: A total of 110 surveys were completed (88% response rate). The median age
of respondents was 55 years (54.1%), and 78.9% were female. Fifty-seven patients
(51.8%) had symptoms for over 10 years, 24.5% for 5-10 years, 17% for 2-4 years and
6.4% for less than a year. Time to diagnosis from onset of symptoms was more than 5
years in 50% and 10 years in 30%. The diagnosis was made by a dermatologist in
45.8% of patients. Associated conditions included hypertension (23.6%) food
allergies (59.3%), and gastrointestinal symptoms (69.4%). There was no family
history of mastocytosis in 87% of patients. Most patients (84.5%) carry an Epipen and
53.6% have medic alert identification. Triggers included histamine releasers,
temperature extremes, emotional and physical stress, fragrances or chemical odors,
friction, physical exertion, latex and rubber.
Conclusion: From this large sample of patients with mastocytosis, it is clear that we
need more education and support for both patients and clinicians. The diversity of
identified triggers, and lack of medical alerts in many patients are important findings.
Dermatologists can minimize delay to diagnosis by considering this condition more
often in patients presenting with compatible symptoms. These patients are
susceptible to severe reactions to both environmental exposure and therapeutic
interventions. Earlier diagnosis plus frequent ongoing dialogue would ensure
recognition of triggers and optimization of treatment and quality of life.
Commercial support: None identified.
Commercial support: None identified.
P8377
P7823
Cutaneous involvement of multiple myeloma mimicking Kaposi sarcoma
Lynne Napatalung, MD, Mayo Clinic, Scottsdale, AZ, United States; David
Swanson, MD, Mayo Clinic, Scottsdale, AZ, United States; James Macdonald,
MD, Mayo Clinic, Scottsdale, AZ, United States
Background: Cutaneous involvement of multiple myeloma (MM) is rare. If present,
cutaneous metastases are typically seen in more advanced MM and confer a poor
prognosis. We report the case of a patient with MM who had development of purple
papules on the foot and was suggestive of an initial diagnosis of Kaposi sarcoma.
Case: A 71-year-old woman received a diagnosis of MM in 2007, which continued to
progress over the next 2 years despite chemotherapy. Cutaneous lesions began to
develop: specifically, smooth, purple, dome-shaped papules on the right dorsal foot
that were aggregated just proximal to the toes. The favored clinical diagnosis was
Kaposi sarcoma, iatrogenic-immunosuppression subtype. However, histopathologic
analysis of a 3 mm punch biopsy showed a dense, diffuse infiltrate of atypical,
immature, anaplastic plasma cells extending throughout the dermis, consistent with
MM of the skin. The diagnosis of cutaneous MM was made. Given this poor
prognostic finding, a more aggressive chemotherapy regimen was initiated. Despite
this addition, five months later, biochemical progression of the malignancy was
evident.
Discussion: Although cutaneous involvement in MM is rare, a typical clinical
presentation has been established, with variations in morphology and distribution.
Clinicopathologic correlation was essential in successfully interpreting this unusual
presentation. Ascertaining the correct diagnosis is critical because cutaneous
involvement of MM portends a worse prognosis and shorter survival and affects
therapeutic planning.
Commercial support: None identified.
AB40
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8465
P8100
Cutaneous Loxoscelism: A diagnosis to consider
Lauren Strazzula, Massachusetts General Hospital, Boston, MA, United States;
Daniela Kroshinsky, Massachusetts General Hospital, Boston, MA, United States;
William Tsiaras, Massachusetts General Hospital, Boston, MA, United States
A 17 year-old healthy female presented with a 1-month history of 2 adjacent
nonhealing ulcers on her left lower leg, The patient had been awakened from sleep 1
month prior with sharp calf pain while sleeping in a sleeping bag at a friend’s house.
She noticed 2 pink papules at that time that subsequently became violaceous,
bullous, and then ulcerated. She reported associated myalgias and mild arthralgias.
The patient was subsequently seen by her primary care physician and received two
courses of sulfamethoxazole/trimethoprim for possible MRSA cellulitis. Because of
the persistence of her symptoms, she then presented to the emergency department
for dermatologic evaluation. Review of photos taken by her family, her clinical
presentation, and the morphology of her lesions were concerning for a Loxosceles
spider bite. Basic chemistries and hematology laboratories were within normal
limits. A punch biopsy demonstrated an arthropod assault with toxin mediated fat
necrosis likely secondary to a Loxosceles spider bite. The toxins from venomous
spider bites result in a local cutaneous reaction known as necrotic arachnidism. In
the United States, Loxosceles reclusa (brown recluse spider) is the most common
spider associated with this phenomenon. The ‘‘red, white, and blue’’ sign describes
the initial erythema, subsequent toxin-mediated vasoconstricted pallisading ring,
and ultimate bluish necrotic ulcer that is the pathognomic pattern of lesion
progression and was documented in this patient. Along with local necrosis, the
spider’s toxins can rarely lead to systemic loxoscelism which can present with fever
and myalgias and may progress to hemolytic anemia, DIC, and death. The patient in
this case was treated with local wound care and seen in the outpatient setting until
the ulcers healed. Cutaneous loxoscelism is an important diagnosis to consider, as
systemic involvement, while rare, may be fatal.
Delusional infestation presenting with shared delusions: Treatment
outcomes from a case series
Alia Ahmed, MBBS, Barts Health NHS Trust, London, United Kingdom; Anthony
Bewley, MBBS, Barts Health NHS Trust, London, United Kingdom; Reena Shah,
PhD, Barts Health NHS Trust, London, United Kingdom; Ruth Taylor, MBBS, Barts
Health NHS Trust, London, United Kingdom
Commercial support: None identified.
Background: Delusional infestation (DI) is the persistent belief of pathogenic
infestation of the skin or body, without objective medical evidence. Shared delusions
can occur between the index case and another individual (folie a deux), and rarely
folie a trois may occur.
Objectives: The aim of this case review was to investigate treatment outcomes for a
series of patients who had DI coexistent with shared delusions (ie, folie a
deux/trois).
Methods: Three 3 patients who had a diagnosis of DI and shared delusions were
identified from a specialist psychodermatology clinic database. Treatment measures
and outcomes for the index case and others involved were assessed via medical
records and patient letters.
Results: All the index cases suffered from DI (2 females, 1 male, age range 35-52
years, mean age 42 years). Two index cases had a diagnosis of DI with folie a trois and
1 case had DI with folie a deux. The patients sharing the delusions were either the
spouse of the index case and/or their children. Treatment of 2 of the index cases
with an atypical antipsychotic (risperidone) and topical treatment (including
antimicrobial emollient therapy) resulted in resolution of the symptoms. Those
sharing the delusions were treated topically and experienced symptom resolution
without systemic treatment once the index case had been treated. One index case
did not comply with risperidone and was treated with a selective serotonin reuptake
inhibitor (citalopram); his wife also required the same treatment. Their symptoms,
although improved, did not resolve completely.
Conclusions: This is the first case series report of treatment outcomes for patients
presenting with DI and shared delusions. It is important to ask patients when they
present whether their spouse, children, or any other members of their family/friends have similar symptoms. Treatment of the index case with risperidone and
topical treatment can result in resolution of symptoms. Those sharing the delusions
can be treated topically and symptoms usually resolve without systemic treatment. It
is likely once the index case experiences relief from symptoms, those sharing the
delusions will follow suit.
Commercial support: None identified.
P8654
Dermatitis herpetiformis: An entity probably underdiagnosed
Marıa Salazar-Nievas, MD, San Cecilio Hospital, Granada, Spain; Juan M.
Rubio-L
opez, MD, Jaen City Hospital Complex, Jaen, Spain; Vicente
Crespo-Lora, MD, San Cecilio Hospital, Granada, Spain
P8282
Cutaneous RosaieDorfman disease coexisting with nontuberculous
mycobacterial infection
Shang-Ian Tee, MBBS, National Skin Centre, Singapore, Singapore; Hiok Hee Tan,
MBBS, Thomson Specialist Skin Centre, Singapore, Singapore
Cutaneous RosaieDorfman disease (RDD) is a rare benign histiocytic proliferative
disorder limited to the skin. Its eitiology is unknown, although viral infection was
postulated as a possible cause. We report a case of RDD in which nontuberculous
mycobacterium (NTM) were found within the lesions on the skin. A 61-year-old
Chinese female presented with a 5-month history of a slowly expanding asymptomatic 6- 3 5-cm erythematous plaque on her right upper arm. She was otherwise
in good health and did not recall preceding trauma. The regional lymph nodes were
not palpable. Skin biopsy revealed a diffuse and nodular infiltrate of histiocytes
exhibiting emperipolesis of lymphocytes and plasma cells. Stains for CD68 and S100
protein were positive within the histiocytes. Interestingly, acid fast bacilli were also
seen on ZiehleNeelsen stain and polymerase chain reaction confirmed the presence
of NTM DNA. She was treated with a combination of oral ciprofloxacin 500 mg bd
and clarithromycin 500 mg bd for 7 months, with clinical improvement in the size
and thickness of the lesion. To our knowledge, the association of NTM with RDD has
not been reported before. The clinical improvement encountered with antibiotic
treatment for NTM appears to support an infective eitiology for RDD in our patient,
and should be considered in the work-up of cases in future.
Commercial support: None identified.
Overview: Dermatitis herpetiformis (DH) is a subepidermal bullous disease
characterized by chronic recurrence of itchy, erythematous papules, urticarial
wheals and grouped vesicles that appear symmetrically on the extensor surfaces,
buttocks and back.
Case report: A 46-year-old man born in Senegal was worried about the episodic
appearance of erythematous and vesicular lesions on the trunk, legs, and arms since
last 4 years. The patient did not show relevant medical history or other symptoms
and denied drug intake. The examinations shown he presented small papular and
vesicular lesions which were grouped in small plaques. The differential diagnosis of
eczema, impetigo, prurigo and bullous pemphigoid was established. A punch biopsy
was done with a sample taken from a lesion located in the right forearm. In the
hematoxylineeosin staining is shown findings compatible with dermatitis herpetiformis. The patient was treated with oral dapsona at doses of 50 mg/day and glutenfree diet with improvement.
Comment: Dermatitis herpetiformis is often underdiagnosed. It is important
suspected this disease in patients with vesicular and papular lesions in areas of
extension, very itchy, and no improvement with corticosteroid treatment. Actually,
because of immigration it is necessary that the dermatologists are trained to
diagnose dermatoses in all skin types, especially skin color where physical
examination can be more difficult. A correct and early diagnosis of dermatitis
herpetiformis is essential as this disease is the cutaneous expression of a glutensensitive enteropathy identifiable with celiac disease.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB41
P7668
P7624
Development of a standardized experimental itch model in humans
Martin Metz, MD, Department of Dermatology, Charite - Universit€atsmedizin
Berlin, Berlin, Germany; Daniel Redoules, PhD, Skin Research Center, Pierre
Fabre Dermo Cosmetic, Toulouse, France; Joachim Fluhr, MD, Department of
Dermatology, Charite e Universit€atsmedizin Berlin, Berlin, Germany; Marcus
Maurer, MD, Department of Dermatology, Charite e Universit€atsmedizin Berlin,
Berlin, Germany; Tomasz Hawro, MD, Department of Dermatology, Charite Universit€atsmedizin Berlin, Berlin, Germany; Valerie Mengeaud, PhD, Skin
Research Center, Pierre Fabre Dermo Cosmetic, Toulouse, France
Chronic pruritus is a major symptom in many dermatologic diseases and can
severely impact quality of life. Thus, there is a huge medical need for novel and
effective topical and systemic itch therapies. Experimental models of induced itch in
humans can help in the development and validation of potential new substances. To
this end, we first noninvasively assessed various parameters after skin provocation
with histamine, cowhage (Mucuna pruriens) spicules or negative controls. To
assess effects of the respective provocations, we employed volumetry, thermography and erythema as parameters of inflammation, transepidermal water loss as a
measure of barrier function, and specific itch parameters such as itch intensity and
itch duration using a visual analogue scale (VAS). Overall, 20 healthy volunteers were
challenged with histamine, cowhage spicules, or saline on 1 arm and subsequently
at various time points on the other arm. In contrast to histamine, cowhage-induced
pruritus was not associated with a significant induction of skin inflammation as
measured by volumetry or thermography, and only a slight increase of erythema has
been observed. However, the mean itch intensity over time and the maximum itch
intensity of cowhage were at least comparable to histamine. Interestingly, itch
intensity varied depending on the time point of the second contralateral
provocation. Based on these findings, we standardized the test set up and aimed
to validate the experimental itch model in a double-blind, randomized therapeutic
application of polidocanol 3% solution vs. placebo in 45 healthy volunteers. Here,
we detected a significant reduction of maximum itch intensity (31.6 6 4.8 vs. 21.2
6 3.5 [VAS]; P \.05) and mean itch intensity over time (254.6 6 56.7 vs. 111.0 6
20.4 [AUC of VAS]; P \.05) in polidocanol 3% treated skin as compared to placebo
control. The present study describes the development of a standardized model of
experimental non-histamine-mediated pruritus in healthy volunteers. We confirmed
the validity of the cowhage-induced itch model in a randomized, placebo-controlled
study, showing a significant antipruritic effect of 3% polidocanol vs. placebo.
Drug-induced lichen planus pemphigoides
Andre Laureano, MD, Department of Dermatology and Venereology, Hospital de
Curry Cabral, Lisboa, Portugal; Gabriela Marques Pinto, MD, Department of
Dermatology and Venereology, Hospital de Curry Cabral, Lisboa, Portugal; Jorge
Cardoso, MD, Department of Dermatology and Venereology, Hospital de Curry
Cabral, Lisboa, Portugal
Introduction: Lichen planus pemphigoides (LPP) is a rare autoimmune disease
characterized by the concomitant presence of subepidermal bullae and lichen
planus lesions.
Clinical Report: A 44-year-old woman presented with a 2-month history of
pruriginous papules on her trunk and extremities followed, 6 weeks later, by
bullous lesions on her legs. Physical examination revealed multiple violaceous,
poligonal, flat papules on the trunk and limbs, and tense blisters within the papules
and normal skin on the legs. There was a temporal relationship with the beginning
of oral therapy with gestodene and ethinilestradiol caused by amenorrhea and
elevated levels of beta-esthradiol. Histhology of a lichenoid papule showed
orthokeratotic hyperkeratosis, hypergranulosis and slight acanthosis in the
epidermis, destruction of the dermoepidermal junction with a dermal inflammatory
infiltrate of lymphocytes. Histhology of a bullous lesion showed a subepidermal
bulla with a dermal inflammatory infiltrate composed predominantly of eosinophils.
In addition, direct immunofluorescence of perilesional skin showed a linear band of
C3 at the dermoepidermal junction. A diagnosis of LPP was confirmed with high
titers of ELISA bullous pemphigoid antigen 180. Subsequently, hormonal therapy
was discontinued and oral prednisolone (40 mg/daily) was initiated. After 4 weeks
the pruritus had disappeared and there was no recurrence of new lesions. The dose
of prednisolone was tapered gradually. ELISA repeated after 6 and 12 months
showed a marked decrease in circulating BP180 autoantibodies. This corresponded
with her clinical improvement.
Discussion: Few cases of drug-induced LPP have been reported. Although admitting
a coincidence, given the clinical features and the response to withdrawal of
gestodene and ethinilestradiol, it is possible that these drugs were the cause of the
LPP in our patient. As far as we know, it is the first case of such association.
Commercial support: None identified.
Sponsored (50%) by Pierre Fabre Derm-Cosmetique.
P8048
P7834
DRESS syndrome caused by telaprevir: A case report
Alicia Gonzalez Quesada, Dermatology Department of University Hospital
‘‘Dr. Negrın,’’ Las Palmas de Gran Canaria, Spain; Carolina Medina Gil,
Dermatology Department of University Hospital ‘‘Dr. Negrın,’’ Las Palmas de
Gran Canaria, Spain; Elena Castro Gonzalez, Dermatology Department of
University Hospital ‘‘Dr. Negrın,’’ Las Palmas de Gran Canaria, Spain; Ildefonso
Qui~
nones, Gatroenterology Department of University Hospital ‘‘Dr. Negrın,’’ Las
Palmas de Gran Canaria, Spain; Irene Casta~
no Gonzalez, Dermatology
Department of University Hospital ‘‘Dr. Negrın,’’ Las Palmas de Gran Canaria,
Spain; Jaime Vilar Alejo, Dermatology Department of University Hospital
‘‘Dr. Negrın,’’ Las Palmas de Gran Canaria, Spain
Dermatologic adverse events (AEs) are an existing concern during hepatitis C virus
(HCV) and its classic treatment (peginterferon/ribavirin). New direct-acting
antivirals (telaprevir/boceprevir) have led to significant improvements in sustained
virologic response rates, but have showed to an increase in dermatologic AEs
compared to peginterferon/ribavirin alone. In telaprevir trials, approximately half of
treated patients had rash. More than 90% of these events were mild/moderate and in
the majority of cases, progression to a more severe grade did not occur. In a small
number of cases (6%), rash led to telaprevir discontinuation, whereupon symptoms
commonly resolved. A few cases were classified as severe cutaneous adverse
reaction (SCAR), also referred to as serious skin reactions, a group of rare conditions
that are potentially life-threatening (drug rash with eosinophilia and systemic
symptoms [DRESS], StevenseJohnson syndrome, and toxic epidermal necrolysis). It
is therefore important to distinguish between telaprevir related dermatitis and
SCAR. We report a case of DRESS caused by telaprevir, a specific inhibitor of HCV
serine protease. The patient is a 52-year-old woman with chronic genotype 1
hepatitis C for 5 years of evolution that had been treated with classic drug without
response. She received telaprevir in combination with pegylated interferon alfa-2a
and ribavirin and, 11 weeks later, she developed a generalized pruritic maculopapular exanthema with malaise, fever, facial edema and lymph node swelling. A blood
test revealed eosinophils 650/uL (normal, \500uL), hemoglobin 7.7 g/dL (normal,
12-17 g/dL), creatininte 1.04 mg/dL (normal, 0.4-0.95), alanine aminotransferase 35
U/L (normal, \32 U/L), and glutamyl transferase 157 U/L (normal, \36 U/L).
Histologic examination of a cutaneous biopsy was consistent with a drug rash
reaction. Telaprevir was stopped and continued with peginterferon/ribavirin. She
was treated with topical and oral steroids. Cutaneous and systemic symptoms
improved in 2 weeks and disappeared completely in a month. Telaprevir was
considered the culprit drug. The majority of cutaneous AEs occurring with
telaprevir can be classified as a less, although we must to check the rare signs of
more serious reactions.
Commercial support: None identified.
AB42
Efficacy results using a novel hidradenitis suppurativa endpoint, HiSCR
(hidradenitis suppurativa clinical response), from the placebo-controlled
phase of a phase 2 adalimumab study
Gregor Jemec, MD, Department of Dermatology, Roskilde Hospital, Health
Sciences Faculty, University of Copenhagen, Roskilde, Denmark; Jeffrey Sobell,
MD, Skin Care Physicians, Chestnut Hill, MA, United States; Noah Scheinfeld, MD,
Department of Dermatology, Weil Cornell Medical College Midtown West, New
York, NY, United States; Sarika Sood, MD, AbbVie Inc, North Chicago, IL, United
States; Yihua Gu, MS, AbbVie Inc, North Chicago, IL, United States
Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory skin follicular
disease with symptoms such as recurrent inflamed nodules, abscesses, and fistulas.
We report efficacy results using the novel endpoint Hidradenitis Suppurativa
Clinical Response (HiSCR; ¼ 50% reduction from baseline in total abscess and
inflammatory nodule [AN] count, with no observed increase in either abscess or
draining fistula counts) from the 16-week, double-blind, placebo (pbo)-controlled
phase of a 52-week adalimumab (ADA) study.
Methods: Moderate to severe HS patients (pts) were randomized 1:1:1 (intent to
treat population [ITT]) to pbo (n ¼ 51), ADA 40 mg every other week, 80 mg at Week
0 (W0) (eow, n ¼ 52), or ADA 40 mg every week, 160 mg at W0, 80 mg at W2 (ew, n
¼ 51). For pts with baseline AN count ¼ 3 and draining fistula count ¼ 20 (mITT
population), the following retrospective evaluations are reported for W12 and W16:
percentage of pts achieving HS-Physician Global Assessment (HS-PGA)-based
Clinical Response (non-responder imputation [NRI]); percentage of pts achieving
HiSCR; percentage of pts achieving 50%, 75%, 100% reduction in total AN count
(AN50, AN75, AN100) relative to baseline (NRI), and percent change from baseline
in AN count (last observation carried forward).
Results: mITT population W12 and W16, HS-PGA-based Clinical Response rates (%)
for pbo/eow/ew groups were, 4.7/6.7/25.0 (P \.05 pbo vs ew) and 2.3/6.7/20.5 (P
\ .05 pbo vs ew), respectively. HiSCR response rates (%) at W12 and W16,
respectively, for pbo/eow/ew groups were 16.3/35.6/59.1 (P \.05 pbo vs ew and
pbo vs ewo) and 25.6/33.3/54.5 (P \.05 pbo vs ew). For pbo/eow/ew groups, pts
(%) achieving specified percent reduction in AN counts at W12 were 32.6/42.2/63.6
(AN50); 20.9/28.9/43.2 (AN75); 4.7/6.7/22.7 (AN100); at W16, 34.9/48.9/56.8
(AN50); 27.9/24.4/40.9 (AN75); 2.3/8.9/20.5 (AN100). For pbo/eow/ew groups,
mean percent (%) reduction from baseline in AN count at W12 was 12.2/32.3/60.3,
and at wk16, 19.8/38.8/59.7.
Conclusion: ADA efficacy was demonstrated in moderate to severe HS pts.
Differences for ADA ew versus pbo in HS-PGA-based Clinical Response and HiSCR
at W12 and W16 were statistically significant. Percent improvement in AN counts
was greater after ADA ew treatment. HiSCR appeared more responsive to change
and better able to discriminate improvement in eow-treated pts than HS-PGA-based
Clinical Response and may be a useful new tool to assess HS therapy efficacy.
Sponsored 100% by AbbVie.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8648
Evaluation of microfocused ultrasound with visualization (MFU-V) for
lifting and tightening of facial and neck skin laxity using a customized,
high-density and vectoring treatment approach
William P. Werschler, MD, Premier Clinical Research, Spokane, WA, United States
Background: Microfocused ultrasound has been demonstrated to be safe and
effective for noninvasive dermatologic treatment to produce eyebrow, submentum
and neck lift. This clinical trial evaluated the efficacy and safety of a higher density
treatment with vectoring to optimize efficacy.
Methods: Twenty subjects with facial/neck laxity received 1 customized, highdensity, vectored MFU-V treatment on the face and neck with 2 transducer: 4e4.5
mm (1.2 J) and 7-3.0 mm (0.45 J). Pain was assessed using a validated scale (0-10)
during the treatment. Standardized photographs were taken before treatment,
immediately after treatment, and at each follow-up visit (days 90, 180, and 365). A
masked qualitative assessment was conducted comparing 90-day posttreatment
photographs to baseline. Global Aesthetic Improvement was assessed by the subject
(SGAIS) and the investigator (PGAIS) and Patient Satisfaction Questionnaires (PSQ)
were obtained at 90, 180, and 365 days posttreatment.
Results: Twenty subjects were treated (3 male, 17 female) with a mean age of 47
years (range 34-60) and a mean pretreatment BMI of 25.4 (range 21.9-28.5).
Fitzpatrick skin types II-III (II e 85.0% and III - 15%) were enrolled. The mean pain
score at each depth was 4.8 at 4.5 mm and 3.28 at 3.0 mm. Subjects received on
average 684 lines (range, 609-700) on the cheeks, submentum, submandular,
periorbital and brow regions during their treatment. SGAIS and PGAIS was 90% and
100% ‘‘improved’’ to ‘‘very much improved’’ at 90 days compared to baseline.
Masked qualitative assessments were completed comparing 90 day posttreatment to
baseline, assessors noted change in 46% of evaluable subjects. 95.0% of subjects
noticed an improvement, were satisfied with the results and noted ‘‘less sagging’’ at
90 days. At 180 days, SGAIS and PGAIS was 94.7% and 100% ‘‘improved’’ to ‘‘very
much improved’’ respectively and 94.7% for both SGAIS and PGAIS at 365 days.
94.7% of subjects noticed improvement at 180 and 365 days respectively. 100% of
subjects were satisfied with the results at 180 day and 94.7% at 365 days. No serious
or treatment related adverse events were reported.
Conclusion: According to the results, a high density MFU-V treatment with a
vectoring approach demonstrated appreciable improvement in GAIS and high
patient satisfaction at 90, 180, and 365 days. The primary limitation in this study is
that photograph quality and consistency in lighting across the time points made
conducting the masked assessments difficult.
A research grant for this study was provided by Ulthera, Inc.
P8493
Evaluation of the safety and effectiveness of microfocused ultrasound with
visualization (MFU-V) for the treatment of erythematotelangiectatic
rosacea
Mark Lupin, MD, The Department of Dermatology and Skin Science, University of
British Columbia, Vancouver, Canada
Background: Rosacea is a common, chronic cutaneous disorder, primarily of the
central face (cheeks, chin, nose, and central forehead), characterized by remissions
and exacerbations. The disorder has 4 main subtypes: erythematotelangiectatic,
papulopustular, phymatous, and ocular rosacea. The objective of this pilot study was
to evaluate the effectiveness and safety of MFU-V for the noninvasive treatment of
erythematotelangiectatic rosacea.
Methods: Subjects with a clinical diagnosis of erythematotelangiectatic rosacea were
randomized to 2 groups for phase I and with an optional phase II. Group A subjects
received one MFU-V treatment with 15 lines on each cheek, group B subjects
received 2 treatments 14 days apart with 15 treatment lines on each cheek with
either the 10-1.5 mm, 7-3.0 mm, or 4-4.5 mm transducer. Subjects’ pain was
measured immediately after treatment. Photographs were taken before and
immediately after treatment and at 14, 30, and 90 days after treatment. The primary
efficacy endpoint was measured by improvement in erythema in the treatment area
versus control (untreated area) as determined by primary investigator assessment at
last follow-up visit in phase I; 90 days after treatment #1 (group A) and 90 days after
treatment #2 (group B). A Patient Satisfaction Questionnaire (PSQ) was collected at
90 days after treatment. Safety, based on adverse event (AE) incidence was assessed.
Results: Twelve subjects with a mean age of 49.8 years (range, 35.4-62.5) and a mean
pretreatment BMI of 27.1 (range, 20.6-32.3) were treated. At interim analysis time
point, physician assessment of improvement for subjects in group A treated with the
10-1.5 mm transducer were 0%, 25%, and 0% at 14, 30, and 90 days posttreatment,
respectively. For group A subjects treated with the 7-3.0 mm transducer, 50%, 75%
and 50% were rated as improved at the 14-, 30- and 90-day follow up visits,
respectively. For group A subjects receiving treatment with the 4-4.5 mm transducer,
25%, 75% and 50% were rated as improved based on physician assessment at the
same follow-up time points. 33% of subjects noticed an improvement and 17% were
satisfied with the treatment at 90 days. Physician assessment of subjects in group B
treated with the 10-1.5 mm transducer and rated as improved were 50% at 14 days,
75% at 30 days, and 75% at 90 days after the second treatment. 75% of group B
subjects treated with the 7-3.0 mm transducer were rated as improved by physician
assessment at days 14, 30 and 90 after the second treatment. For group B subjects
treated with the 4-4.5 mm transducer, 50% were rated as improved based on
physician assessment and 100% at days 30 and 90 after the second treatment. 67% of
subjects noticed an improvement and 50% were satisfied with the treatment at 90
days. No serious adverse events were reported. No treatment related adverse events
were reported.
Conclusion: Data from this pilot study suggests that 2 deep depth treatments of MFUV are superior to 1 treatment and superior to superficial treatment for the treatment
of erythematotelangiectatic rosacea. The primary limitation is that presently only
preliminary data is available; subjects enrolled in phase II have received treatment
with either the 7-3.0 mm or 4-4.5 mm transducer. Follow-up visits will be completed
in October 2013.
Supported by Ulthera.
P8280
Evolution of urticarial vasculitis: A clinical, dermoscopic, and histopathologic study
Kee Suck Suh, MD, Department of Dermatology, Kosin University College of Medicine,
Busan, South Korea; Jong Bin Park, MD, Department of Dermatology, Kosin University
College of Medicine, Busan, South Korea; Kang Hoon Lee, MD, Department of
Dermatology, Kosin University College of Medicine, Busan, South Korea; Min Soo
Jang, MD, Department of Dermatology, Kosin University College of Medicine, Busan,
South Korea; Sang Hwa Han, MD, Department of Dermatology, Kosin University
College of Medicine, Busan, South Korea; Sang Tae Kim, MD, Department of
Dermatology, Kosin University College of Medicine, Busan, South Korea
Background: The clinical differentiation of urticarial vasculitis (UV) and urticaria,
especially in urticarial skin lesions arising within 24 hours, is a diagnostic challenge.
Recently, polarized dermoscopy (PD) with a cross-polarized lens was shown to provide
a superior view of deeper skin structures, such as vascular structures and the reddish
hue associated with some lesions, when compared to nonpolarized dermoscopy.
Objectives: We aimed to analyze clinicodermoscopic findings in patients with UV
and disease progression in relation to histologic findings and to evaluate the
usefulness of PD in the diagnosis of urticarial skin lesions through a comparative
dermoscopic study between patients with UV and urticaria.
Methods: Eleven patients (4 men and 7 women: mean age, 39.82 6 18.70) clinically
and histologically diagnosed with UV were enrolled. Clinical findings and dermoscopic patterns were evaluated throughout the course of disease. Skin biopsy
specimens were performed on early and late lesions, and an attempt was made to
associate dermoscopic features with histopathologic findings. To assess the
diagnostic value of PD in this disease setting, 22 consecutive patients with a clinical
diagnosis of common urticaria in the past year (10 men and 12 women: mean age,
36.21 6 12.50) were selected.
Results: Most patients with UV had early erythematous urticariform patches or
wheals (11/11) and late purpuric patches (9/11). Dermoscopically, linear vessels
were found in early (5/11) and late lesions (2/11), as were a homogeneous
erythematous background (11/11 and 2/11, respectively) and a purple-brown
background (1/11 and 10/11, respectively). Red-purple dots or globules had higher
mean values in late lesions (mean grade, 2.36) than in early lesions (mean grade, 1.0),
and dermoscopy showed development of a prominent purplish hue with time. In
early lesions, histologic analysis showed early phases of leucocytoclastic vasculitis
(LCV), while late lesions demonstrated fully developed LCV. The incidence of linear
vessels (19/22; P ¼.033) was significant in common urticaria whereas the incidence
of red-purple dots or globules (10/11; P ¼.000) was distinct in early stage UV.
Conclusion: Our study confirms the observations of a previous study with regard to
the initial screening of urticarial lesions by dermoscopy. In addition, PD may be
particularly useful in differentiating early UV from early common urticaria lesions.
Commercial support: None identified.
P8470
Eyelid trichoadenoma
Thais Mesquita, MD, Thais de Paula Amorim Mesquita, Uberlandia, Brazil; Maria
Cristina Mesquita, MD, Maria Cristina de Paula Mesquita, Uberlandia, Brazil;
Renata Kobata, MEd, Renata Scarabucci Janones Kobata, Uberlandia, Brazil
First described in 1958 by Nikolowski, trichoadenoma is a slow growing benign skin
tumor that is rare, solitary, asymptomatic, with no malignancy potential. It originates
from cells of the hair follicle, located mainly on the face, trunk and buttocks, being
more frequent in the fourth decade. Trichoepithelioma and basal cell carcinoma are
the main differential diagnoses. There are few cases reported in the literature, so the
rarity of this tumor and the unusual location, as the eyelid is scare in hair follicles, led
us to describe this case. Female, 48-year-old, noticed 3 years ago a slightly
erythematous, hard lesion on her right lower eyelid. On that occasion, underwent
excision of the lesion and the histologic diagnose was hemangioma. Two years and a
half later, she noticed, at the site of the prior lesion, a small papule, treated with
topical fusidic acid and betamethasone valerate, without success. Two months later,
a biopsy has diagnosed trichoepithelioma. Motivated by the appearance of the lesion
and possible risk of malignancy, she came to our service. Physical examination
detected a slightly erythematous 1.3 cm plaque, with multiple small yellowish cysts
arround, some translucent, bright, and with small and thin vessels on the surface
(Figs 1 and 2). A histologic slide review by another pathologist confirmed the clinical
suspicion of trichoadenoma, with extensive sudoriparous squamous metaplasia
(Figs 3 and 4). Treatment strategy consisted of surgical resection with exiguous
margins, along with microscopy freezing in the operating room. Trichoadenoma
shows greater maturity than trichoepithelioma and lower differentiation than the
trichofoliculoma and the desmoplastic trichoepithelioma. Some authors believe that
this is an intermediate pathology in the differentiation for the infundibular channel
pilosebaceous segment between trichoepithelioma and trichofoliculoma. Clinically,
it presents as a single well-defined nodular lesion or lowercase confluent papules,
coloring slightly different from the surrounding skin, covered with telangiectasias
and measuring from a few millimeters to 1.5 cm. Histopathology shows multiple
cysts filled with keratin lined by squamous cells in the dermis. It’s usually sporadic,
but are cases related to other skin conditions, such as sebaceous nevus and
melanocytic nevus. Some authors question its existence, considering it as a variety of
trichoepithelioma or keratinizing basal cell carcinoma.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB43
P8176
P7567
Facial Becker nevus associated with fibrous dysplasia and facial
asymmetry
Sue Ann Chan, MBChB, Birmingham Skin Centre, Birmingham, United Kingdom;
Amirtha Vani Rajasekaran, MBChB, Birmingham Skin Centre, Birmingham, United
Kingdom
GardnereDiamond syndrome
Nathan Cleaver, DO, St. Joseph Mercy Hospital, Ypsilanti, MI, United States;
David Altman, MD, St. Joseph Mercy Hospital, Ypsilanti, MI, United States; Stuart
Gildenberg, MD, St. Joseph Mercy Hospital, Ypsilanti, MI, United States
A 30-year-old white female presented with a 5-day history of complaints of low back
pain with lower extremity numbness and tingling. She stated her symptoms began
abruptly while watching television. There was no history of trauma or injury to her
low back. The patient’s past medical and surgical history was unremarkable. The
patient admitted to significant personal stress in her life. On physical examination,
the patient was emotionally labile and tearful. She had clustered purpuric patches in
multiple stages of healing scattered on the central lower back. Upon palpation, the
patient claimed pain of 10/10. On the same visit, another resident physician
performed the same examination independently, but elicited only minimal
tenderness upon palpation. Following an inconclusive neurologic and hematologic
work-up, the diagnosis of GardnereDiamond syndrome was made. In 1955, Gardner
and Diamond first described a condition in which purpura was produced by
hypersensitivity to extravasated erythrocytes. In 1968, Ratnoff and Agle proposed
the name psychogenic purpura, as lesions often occurred in association with
psychiatric problems such as depression, anxiety, histrionic or conversion personality disorder. GardnereDiamond syndrome (autoerythrocyte sensitization syndrome, psychogenic purpura) is characterized by the sudden onset of painful,
swollen bruises of variable sizes in a particular area of the body. The lesions are often
precipitated by emotional stress, and are primarily seen in middle-aged women,
although it has been less commonly reported in males and children. In many
patients, this will recur, often remitting for months to years with relief of emotional
stressors. The lesions tend to spontaneously resolve in about 2 weeks, with no
fatalities or serious complications reported in association with the disease. There
have been no therapeutic interventions that have proved beneficial other than
psychotherapy to date.
Introduction: Becker nevus is a pubertal onset epidermal nevus, more common in
males, associated with hyperhidrosis, hypertrichosis, and melanosis triggered by
circulating androgens. We report an interesting case of Becker nevus associated with
fibrous dysplasia of maxillary bone and facial asymmetry.
Case report: A 32-year-old man was referred by his General Practitioner with
reduced density of hair growth over his left side of his face since puberty. He
generally shaves his right side of his face twice a day, while barely requiring to shave
his left side of the face to maintain symmetry. Interestingly, he gives history of fibrous
dysplasia of his right maxilla, requiring dental transplant of his UR5 (upper right 5)
and UR8 at age 20. He had childhood asthma and eczema and is hypertensive. He
does not report any family history of genetic disorders. He is married with 1 child
who has 3 cherry hemangiomas but otherwise very well. His regular medications
include lisinopril and furosemide. Examination revealed increased hair growth on
the right side of the face with hyperhidrosis. A mild facial asymmetry was also noted
with more prominent nasolabial fold on the right side. There is no sensorineural
deficits. Eyelashes, eyebrows, and scalp hair were symmetrical. This patient was
discussed in depth at the West Midlands Regional Clinical Meeting and a possible
diagnosis of Becker nevus was postulated. Punch biopsies were taken from each side
of his face for comparison. Biopsy from the left cheek was normal while the biopsy
taken from the right cheek revealed mild epidermal acanthosis, prominent hair
follicles and smooth muscle hypertrophy of the arrectores pilorum as well as smooth
muscle bundles in the dermis. There was also mild perivascular chronic inflammation in the superficial dermis. These findings confirm a diagnosis of a Becker nevus
on the right side of the face.
Discussion: Interestingly, our patient and General Practitioner’s concern was
predominantly the lack of hair growth on the left side of his face rather than the
hypertrichosis on his right side. It was very difficult to ascertain the focus of
pathology in the initial stages—the lack of hair on the left side or the hypertrichosis
on the right side. We reinforce the importance of adapting an open approach when
managing dermatologic patients to obtain the correct diagnosis and treatment plan
for our patients.
Commercial support: None identified.
Commercial support: None identified.
P7986
P7717
Facial lumps and bumps
Ha Do, MD, MS, Indiana University, Dermatology Department, Indianapolis, IN,
United States; Daniel West, MD, Indiana University, Dermatology Department,
Indianapolis, IN, United States; Jessica LeBlanc, MD, Indiana University,
Dermatology Department, Indianapolis, IN, United States; Yongxue Yao, MD,
PhD, Indiana University, Dermatology Department, Indianapolis, IN, United
States
Giant cell tumor of the hand: A case report
Manuel Valdebran, MD, Instituto Dermatol
ogico y Cirugıa de Piel ‘‘Dr. Huberto
Bogaert Dıaz,’’ Santo Domingo, Dominican Republic; Angel Taveras, MD, Instituto
Dermatol
ogico y Cirugıa de Piel ‘‘Dr. Huberto Bogaert Dıaz,’’ Santo Domingo,
Dominican Republic; Eduardo Sanchez, MD, Instituto Dermatol
ogico y Cirugıa de
Piel ‘‘Dr. Huberto Bogaert Dıaz,’’ Santo Domingo, Dominican Republic; Fernanda
Nanita Estevez, Instituto Dermatol
ogico y Cirugıa de Piel ‘‘Dr. Huberto Bogaert
Dıaz,’’ Santo Domingo, Dominican Republic; Nery Ramırez, MD, Instituto
Dermatol
ogico y Cirugıa de Piel ‘‘Dr. Huberto Bogaert Dıaz,’’ Santo Domingo,
Dominican Republic; Rossy Nu~
nez, MD, Instituto Dermatol
ogico y Cirugıa de Piel
‘‘Dr. Huberto Bogaert Dıaz,’’ Santo Domingo, Dominican Republic
Background: Giant cell tumor (GCT) of phalanx is a rare entity accounting for
approximately 2% to 5% of all giant cell tumors. Metaphyseal region of the
metacarpals and phalanges is the site of origin for most of these tumors. Though
GCT is not a sarcoma, those located in the finger appear to behave more aggressively
often requiring extensive en bloc excision.
Various dermatologic conditions can give rise to or are associated with facial lumps
and bumps. We present 3 interesting facial lumps and bumps cases with great
clinical photographs, histopathology photos, and clinical pearls to highlight the key
teaching points for each case. We include both common presentations for rare
conditions and rare presentations for rare conditions. The first case is a 61-year-old
female with history of sarcoidosis presented with secondary miliary osteoma cutis of
the cheeks. These lesions are considered as metaplastic ectopic ossification in
previously active facial cutaneous sarcoid lesions. The second case is a 60-year-old
male with previously undiagnosed Birt-Hogg-Dube syndrome who presented for an
unrelated problem. The facial papules led a series of questions that increased the
suspicion for the diagnosis, and biopsy of the papules allowed confirmation and
initiation of proper clinical follow-up. The third case is a 54-year-old female who
demonstrated an unusual presentation of localized central facial papules that turned
out to be nodular amyloidosis. Amyloidosis teaching points are reviewed.
Case report: A 23-year-old female presented to our institution with a tender swelling
of her left middle finger, which has been present for only 1.5 months. Physical
examination was otherwise normal, regional nodes were not palpable. Routine
serological testing and a chest radiographs were inconspicuous. Radiographs of the
hand revealed expansile multiloculated lytic lesion involving the entire middle
phalanx with cortical break but preserved articular spaces. The lesion was
completely removed by en bloc resection of the third finger of her left hand.
Biopsy of the specimen showed a mesenchymal lesion characterized by proliferation
of fibroblasts, histiocytes and abundant multinucleated giant cells.
Commercial support: None identified.
Commercial support: None identified.
AB44
Discussion: When GCT occur in the hand, they frequently cause severe bony
destruction and extend into the surrounding soft tissues. This case was unique
considering the comparative rarity of a giant cell tumor arising from the phalanges of
the finger. A review of the literature demonstrates a paucity of such cases. Because of
the higher risks for local recurrence, treatment should be aggressive.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P7906
P8431
Groin ulcers secondary to severe aortic atherosclerosis—A mimicker of
calciphyalxis
R. Erin Lopez, MD, Department of Dermatology, Geisinger Medical Center,
Danville, PA, United States; Eric Hossler, MD, Department of Dermatology,
Geisinger Medical Center, Danville, PA, United States
Handefoot syndrome in patients treated with sorafenib: Report of 2 cases
Ana Pampın, MD, Hospital Universitario Fundaci
on Alcorc
on, Alcorc
on, Spain;
Dolores Caro-Gutierrez, MD, Hospital Universitario Fundaci
on Alcorc
on,
Alcorc
on, Spain; Enrique G
omez-de la Fuente, MD, Hospital Universitario
Fundaci
on Alcorc
on, Alcorc
on, Spain; Jose Luis L
opez-Estebaranz, MD, Hospital
Universitario Fundaci
on Alcorc
on, Alcorc
on, Spain; Reyes Gamo, MD, Hospital
Universitario Fundaci
on Alcorc
on, Alcorc
on, Spain
Background: The differential diagnosis for cutaneous ulcers is vast. We present a
unique presentation of ulcerated purpuric plaques on the buttocks, groin and distal
extremities secondary to severe aortic atherosclerosis.
Case report: 68-year-old female with a history of myocardial infarction and
cerebrovascular accident presented with a 2-month history of progressive painful
ulcers on the buttocks, thighs, and groin. The physical examination revealed
multiple tender ulcers covered with adherent black eschars and indurated subcutaneous plaques with overlying purpura located in the medial upper thighs and
buttocks. Despite the lack of known renal disease, calciphylaxis was suspected. An
incisional biopsy was performed and revealed ischemic necrosis with fibrin thrombi
but no evidence of vascular calcium deposition. Ankleebrachial indices showed
severe bilateral peripheral arterial disease. Subsequent angiography of the abdominal aorta revealed near occlusion of the distal abdominal aorta and both common
iliac arteries also showed severe occlusive disease. The patient subsequently
underwent an aortobiiliac bypass graft and experienced pain relief and near full
healing of the wounds before succumbing to bowel obstruction.
Conclusion: Physicians should be aware of this unusual presentation of severe aortic
ischemia as a potential diagnosis when patients present with calciphylaxis-like
findings on physical examination.
Commercial support: None identified.
Sorafenib is a vascular endothelial growth factor receptor (VEGFR) tyrosine kinase
inhibitor, and it is used for the treatment of diverse cancers. Several cutaneous
adverse events have been related with sorafenib. We report 2 cases of hand-foot
syndrome (HFS) in patients treated with sorafenib. A 78-year-old man with
metastatic hepatocellular carcinoma and an 84-year-old woman with advanced
renal cancer were receiving sorafenib at dosage of 800 mg and 400 mg per day,
respectively. Several days after the beginning of the treatment, they presented with
very painful bullous lesions with intense inflammatory reaction at the perilesional
area. All of them were localized at hyperkeratotic areas induced by mechanical
pressure and friction on his palms and soles. Some of the lesions were erosive, and
they were very painful. Pyridoxine and clobetasol were started with poor response.
HFS, also known as palmar-plantar erythrodysesthesia, usually begins with
paresthesias, swelling or pain on the palms and soles. It is characteristic the
presence of erythema, and sometimes scaling and erosions or bullae formation. HFS
has been described in association with multiple antineoplastic drugs. In the last
years, it has been related to oral VEGFR tyrosine kinase inhibitors, such as sorafenib.
HFS caused by these chemotherapic agents differs on HFS caused by other
antineoplastic drugs. Sorafenib produces its effects on angiogenesis through the
inhibition of the VEGFR, which leads to an alteration on reparation mechanisms.
This explains that HFS related to sorafenib usually develops at sites affected by
chronic microtrauma, callosities, and friction areas, what leads to a predominant
affection of the feet. In HFS caused by different chemotherapic agents, lesions do not
have this predilection for mechanical pressure affected areas. Other differences are
that type III hypersensitivity reactions often occur with VEGFR inhibitors, and
lesions are also more painful in comparison with HFS produced by other
antineoplastic agents, with severe alteration on the quality of life of the patients.
Therefore, HFS often requires dose reduction, interruption or switch in the
chemotherapic agent. In conclusion, we report 2 cases of HFS in patients treated
with sorafenib, with distinctive features that difference VEGFR related HFS from HFS
caused by classic chemotherapic agents. Dermatologists must recognize this
syndrome, in order to reduce complications and improve it management.
Commercial support: None identified.
P8527
Grover disease associated with chemotherapy
Daniel Butler, University of Arizona College of Medicine, Tucson, AZ, United
States; Jubin Ryu, MD, PhD, UCSF Department of Dermatology, San Francisco,
CA, United States; Kanade Shinkai, MD, PhD, UCSF Department of Dermatology,
San Francisco, CA, United States; Matthew Goldberg, MD, UCSF Department of
Dermatology, San Francisco, CA, United States; Timothy McCalmont, MD, UCSF
Department of Dermatology, San Francisco, CA, United States
Recently, the range of cutaneous reactions to chemotherapeutic agents was
reorganized under the umbrella of toxic erythema of chemotherapy (TEC).
Herein, we present 2 cases of patients receiving polychemotherapy for hematologic
malignancies who developed widespread pruritic eruptions after initiation of
therapy both subsequently found to be consistent with Grover disease. While there
are reports in the literature linking the use of certain chemotherapeutic agents to the
development of Grover disease, we propose that the observed clinical and
histopathologic features may be best characterized along the spectrum of TEC.
The first patient was a 67-year-old man with acute myeloid leukemia who was
undergoing chemotherapy with panabinostat, cytarabine, and daunorubicin. On
treatment day 12, he developed an eruption of erythematous indurated papules on
his back and dorsal surface of his hands. The lesions spread over the next 4 days to
involve the legs, groin, chest, with accentuation beneath his PICC line dressing.
Biopsy specimens from both the trunk and lower leg revealed prominent
acantholysis with slight dyskeratosis arising from a background of subtle epidermal
dysmaturation. These findings were consistent with classic Grover disease with
evidence of chemotherapy effect in the surrounding epidermis. The second patient
was a 63-year-old woman undergoing an allogenic peripheral blood stem cell
transplant as treatment for myelodysplastic syndrome. On day 2 of induction
chemotherapy with busulfan and fludarabine, she developed erythematous papules
over her buttocks, which subsequently spread to her chest, abdomen, and proximal
extremities. Biopsy specimens revealed prominent acantholysis and dyskeratosis
amidst a background of significant epidermal dysmaturation. These findings
indicated classic TEC with concurrent acantholytic dyskeratosis, consistent with
Grover disease. Classic Grover disease is a common, benign, self-limited process and
these 2 cases highlight that similar clinical and histopathologic features can be seen
after administration of chemotherapy. These cases provide further evidence that
when identified in this context, Grover disease can be understood as a cutaneous
chemotherapy effect. Further research to establish Grover diseaseelike changes as
part of the TEC spectrum would be diagnostically useful and clinically relevant in the
care of patients undergoing chemotherapy.
Commercial support: None identified.
P8297
Idiopathic lipoatrophic panniculitis in an adult
Hari Reddy, MBBS, University Hospital of North Durham, Durham, United
Kingdom; Sivakumar Natarajan, MD, The James Cook University Hospital,
Middlesbrough, United Kingdom
A 67-year-old woman presented with a 12-month history of painful red nodules over
both legs. The patient was otherwise healthy and medical history was noncontributory. The physical examination revealed large, indurated, erythematous plaques on
her right leg and smaller plaques on her left leg. Most notable was the marked
lipoatrophy that had already occurred after earlier episodes with prominence of her
veins. Investigations showed a normal blood cell count, serum electrolytes, liver
function tests, glucose, amylase, creatinine kinase, alfa-1-antitrysin, ferritin, and
complements. Serum protein electrophoresis, ANA and autoantibodies, ENA, ANCA,
hepatitis screen, TB screen were negative. Ultrasonograpy of the abdomen and
pelvis was normal. Histologic evaluation of a biopsy specimen from the lower leg
demonstrated lobular panniculitis without vasculitis. Lipophagic histiocytes were a
prominent feature, and scattered lymphocytes and eosinophils were also seen. A
diagnosis of idiopathic lipoatrophic panniculitis was made. Our patient was treated
with a reducing course of prednisolone starting at 20 mg and reducing by 5 mg every
5 days. This promptly settled her symptoms and importantly prevented any further
lipoatrophy. Over the next few years, she was treated with oral prednisolone at the
earliest signs of recurrence of her panniculitis, with the above tapering course. She
has shown excellent response to treatment with complete resolution of panniculitis
without further lipoatrophy and no steroid side effects. She remains systemically
well but continues to have residual, symmetrical lipoatrophy of the ankles, legs, and
thighs. While lipoatrophic panniculitis is quite rare and more commonly seen in
children, it has also been reported in adults. Primary or idiopathic lipoatrophic
panniculitis is a diagnosis of exclusion. Secondary lipoatrophic panniculitis may be
caused by connective tissue disorders, such as lupus panniculitis or dermatomyositis; trauma from thermal or chemical sources; infection, including Mycobacteria
and Cryptococcus mycetoma; HIV; malignancy involving a cytophagic histiocytic
panniculitis; and pancreatic disease, including acute pancreatitis, pancreatic
carcinoma and alfa-1-antitrypsin deficiency. Early diagnosis to prevent extension
and disfiguration is key. Treatment options include prednisolone, antimalarial
agents, and dapsone, all of which have varying degrees of efficacy. We present
our case to contribute to the growing body of literature on this relatively uncommon
entity.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB45
P7750
P7747
Imiquimod 2.5% and 3.75% for the treatment of external genital warts:
Additional insights into efficacy
Theodore Rosen, MD, Department of Dermatology, Houston, TX, United States;
Christina Cognata Smith, PharmD, Medicis (a division of Valeant
Pharmaceuticals), Scottsdale, AZ, United States; Mandeep Kaur, MS, MD,
Medicis (a division of Valeant Pharmaceuticals), Scottsdale, AZ, United States;
Stephen Tyring, MD, Department of Dermatology, Houston, TX, United States
Background: The approved imiquimod 5% cream regimen for treating external
genital warts (EGW) requires a long treatment. Daily dosing to reduce the length of
treatment course resulted in a greater incidence and severity of local adverse events
(AEs) without an improvement in efficacy.
Objective: To provide additional insights into the efficacy of imiquimod 3.75% and
2.5% creams in treating EGW.
Imiquimod 2.5% and 3.75% for the treatment of external genital warts:
Assessment of safety in 981 randomized patients
Gary Goldenberg, MD, Mount Sinai School of Medicine, New York, NY, United
States; Anita Nelson, MD, Department of Obstetrics and Gynecology, Torrance,
CA, United States; Christina Cognata Smith, PharmD, Medicis (a division of
Valeant Pharmaceuticals), Scottsdale, AZ, United States; James Del Rosso, DO, Las
Vegas Skin & Cancer Clinic, Las Vegas, Nevada, United States
Background: Imiquimod 5% cream approved regimen for external genital warts (EGW)
requires prolonged treatment. Daily dosing to reduce the treatment course resulted in
a greater incidence and severity of local adverse events (AEs) without efficacy
improvement. More frequent dosing with lower concentrations would seem ideal.
Objective: To assess the safety and tolerability of more frequent dosing with lower
concentration imiquimod cream (3.75% and 2.5%) in treating EGW.
Methods: Two identical multicenter, randomized, double-blind, placebo controlled
studies. Subjects (12 years old) with 2 to 30 EGWs and total wart area of 10 mm2
randomized to imiquimod 3.75%, imiquimod 2.5%, or vehicle cream (2:2:1) once daily
until complete clearance or a maximum of 8 weeks (end of treatment, EOT), with a
follow-up period of up to 8 weeks (end of study, EOS) for subjects who did not achieve
complete clearance by EOT; 12-week observational follow-up period in subjects with
complete clearance by EOS. Primary efficacy endpoint was complete clearance (%
subjects at EOS with zero EGW count). Additional efficacy endpoints were
improvement by study week, 50% reduction in warts, and time to complete cure.
Results: Complete clearance rates were significantly higher than vehicle cream with
imiquimod 3.75% at all assessment time points (including EOT and EOS), and
imiquimod 2.5% at Weeks 6, 10, 12, and 14 in study 1, and from Week 8 in study 2.
Complete clearance was significantly higher with imiquimod 3.75% compared to
imiquimod 2.5% from Week 8 in study 1. The rate of ¼ 50% clearance of EGW at EOT
(43.6-47.7% with imiquimod 3.75%, and 32.6-36.6% with imiquimod 2.5%) and EOS
(49.5-50.8% with imiquimod 3.75% and 34.3-43.1% with imiquimod 2.5%) was
significantly higher compared with vehicle cream. Clearance rates with imiquimod
3.75% were significantly greater than imiquimod 2.5% in Study 1 (P ¼.002/\ .001,
respectively) The median time to clearance was statistically shorter in the
imiquimod 3.75% group (P \.001 in both studies) and the imiquimod 2.5% group
(P ¼ .035/\ .001) compared with vehicle cream. For those subjects who attained
complete clearance, the median time ranged from 52-60 days (imiquimod 3.75%),
56.5-63 days (imiquimod 2.5%), and 67-71 days (vehicle).
Conclusion: In 2 well-controlled phase 3 studies, imiquimod 2.5% and 3.75% creams
were more effective than vehicle cream when administered daily for up to 8 weeks
to treat EGW. Imiquimod 3.75% was generally the more effective.
Methods: Two identical multicenter, randomized, double-blind, placebo controlled
studies. Subjects (12 years old) with 2 to 30 EGWs and total wart area of 10 mm2
randomized to imiquimod 3.75%, 2.5%, or vehicle (2:2:1) once daily until complete
clearance or maximum of 8 weeks (end of treatment, EOT), with follow-up period of
up to 8 weeks (end of study, EOS) for subjects who did not achieve complete
clearance by EOT; 12-week observational follow-up period in subjects with
complete clearance by EOS. Safety assessments included visual assessment of local
skin reaction (LSR), number and duration of study treatment rest periods required
because of intolerant LSRs, AEs, and clinical laboratory tests.
Results: Most AEs were mild or moderate; most commonly reported being
application site reactions in the active treatment groups. Treatment-emergent AEs
leading to study discontinuation were reported in 7, 10, and 1 subjects in the
imiquimod 3.75%, 2.5%, and vehicle groups. Eight subjects in the imiquimod groups
withdrew because of application site reactions, considered related or possibly
related to treatment. Treatment with either imiquimod strength resulted in greater
increases in LSRs compared with vehicle cream. Erythema was reported with the
greatest frequency and mean intensity in all treatment groups. For both active
creams, the number and severity of LSRs decreased rapidly after the completion of
treatment. Rest periods were taken by 126, 104, and 4 subjects in the 3.75%, 2.5%
imiquimod, and vehicle groups, respectively. The frequency, duration, and number
of dosing days before the rest period were similar in the active treatment groups and
lower in the vehicle group. There was no evidence of clinically meaningful trends in
vital sign measurements or clinical laboratory measurements.
Conclusion: In 2 well-controlled phase 3 studies, imiquimod 2.5% and 3.75% creams
were well tolerated, with no significant difference in AEs compared to vehicle, when
administered daily for up to 8 weeks to treat EGW.
Sponsored 100% by Medicis, a division of Valeant Pharmaceuticals.
Sponsored 100% by Medicis, a division of Valeant Pharmaceuticals.
P7745
Imiquimod 2.5% and 3.75% for the treatment of external genital warts:
Assessment of efficacy in 981 randomized patients
Anita Nelson, MD, Department of Obstetrics and Gynecology, Torrance, CA,
United States; Kevin Ault, MD, Department of Gynecology and Obstetrics,
Atlanta, GA, United States; Mandeep Kaur, MS, MD, Medicis (a division of Valeant
Pharmaceuticals), Scottsdale, AZ, United States; Stephen Tyring, MD,
Department of Dermatology, Houston, TX, United States
Background: Imiquimod 5% cream approved regimen for external genital warts
(EGW) requires a long treatment. Daily dosing with this formulation resulted in
greater incidence and severity of local adverse events (AEs) without improving
efficacy. Frequent dosing with lower concentration without compromising efficacy
would be beneficial to patients.
Objective: To assess the efficacy of more frequent dosing with lower concentrations
(3.75% and 2.5%) imiquimod cream in treating EGW.
Methods: Two identical multicenter, randomized, double-blind, placebo controlled
studies. Subjects (12 years old) with 2 to 30 EGWs and total wart area of 10 mm2
randomized to imiquimod 3.75%, 2.5%, or vehicle (2:2:1) once daily until complete
clearance or maximum of 8 weeks (end of treatment, EOT), with a follow-up period
up to 8 weeks (end of study, EOS) for subjects who did not achieve complete
clearance by EOT; and a 12-week observational follow-up period in subjects with
complete clearance at EOS. Primary efficacy endpoint was complete clearance (%
subjects at EOS with zero EGW count). Secondary efficacy endpoints were rate of
partial clearance (75% reduction in EGW count), change in wart count, and 12-week
sustained clearance.
Results: 981 subjects were enrolled (470 subjects Study 1 and 511 subjects Study 2).
Complete clearance rates in the 3.75% and 2.5% imiquimod groups were 27.2%
(Study 1), 29.4% (Study 2) and 19.1% (Study 1), 24.8% (Study 2) respectively
compared to 10.3% (Study 1), 8.6% (Study 2) with vehicle (P \ .001 imiquimod
3.75% versus vehicle). Partial clearance rates were 37.9% (Study 1), 38.7% (Study 2)
and 27.0% (Study 1), 31.2% (Study 2) respectively compared to 13.4% (Study 1),
10.5% (Study 2) with vehicle (P \ .001 imiquimod 3.75% versus vehicle). Mean
lesion count reductions from baseline were 45.8% (Study 1), 40.9% (Study 2) and
26.6% (Study 1), 37.7% (Study 2) respectively for imiquimod 3.75% and 2.5%
compared to 9.4% (Study 1 and 2) for vehicle (P \ .001 versus vehicle). 75.5%
(Study 1) and 64.2% (Study 2) of subjects in imiquimod 3.75% group achieved
complete clearance at EOS, sustained throughout the 12-week follow-up period,
compared to 48.4% (Study 1) and 67.4% (Study 2) in imiquimod 2.5% group.
P7749
Imiquimod 2.5% and 3.75% for the treatment of external genital warts:
Sex differences in a study of 981 randomized patients
Theodore Rosen, MD, Department of Dermatology, Houston, TX, United States;
Gary Goldenberg, MD, Department of Dermatology, New York, NY, United
States; Kevin Ault, MD, Department of Gynecology and Obstetrics, Atlanta, GA,
United States; Mandeep Kaur, MS, MD, Medicis (a division of Valeant
Pharmaceuticals), Scottsdale, AZ, United States
Background: The approved imiquimod 5% cream regimen for external genital warts
(EGW) requires a long treatment period. More frequent dosing with lower
concentrations (2.5% and 3.75%) has been studied, and pooled data in women
previously reported. There is no published data on sex differences in treating EGW.
Objective: To evaluate sex differences with 3.75% and 2.5% imiquimod cream in
treating EGW.
Methods: Two identical multicenter, randomized, double-blind, placebo controlled
studies. Subjects (12 years old) with 2 to 30 EGWs and total wart area of 10 mm2
randomized to imiquimod 3.75%, 2.5%, or vehicle cream (2:2:1) once daily until
complete clearance or maximum of 8 weeks (end of treatment, EOT), with a followup period of up to 8 weeks (end of study, EOS) for subjects who did not achieve
complete clearance by EOT; 12-week observational follow-up period in subjects
with complete clearance by EOS. Primary efficacy endpoint was complete clearance
(% subjects at EOS with zero EGW count). Secondary efficacy endpoints included
rate of partial clearance (75% reduction in EGW count).
Results: 981 subjects were enrolled (447 males, 534 females). Majority of EGWs in
males were on the penile shaft (84.1%), inquinal area (27.3%), or scrotum (25.3%);
and in females the vulva (64.8%), perineal (47.9%), or perianal area (46.4%). Almost
50% of subjects in both subgroups had ¼ 2-affected regions. Complete (EOS) and
partial clearance rates were significantly greater with imiquimod 3.75% in males (P
¼ .015/.019 and P ¼.001/.008, respectively) and females (P ¼.017/\.001 and P ¼
.002/\.001, respectively) in both studies compared to vehicle. More females
achieved complete (29% and 38.8%) and partial (45% and 50%) clearance compared
to males (14.7% and 17.0%, and 30.5% and 23.9%, respectively) with imiquimod
3.75%, and complete clearance at EOT was statistically superior to placebo in both
studies (P ¼.003 and .009), and superior to imiquimod 2.5% in study 1 (P ¼ .017).
Clearance rates with imiquimod 2.5% were greater in the female subgroups of both
studies, but only significantly greater than vehicle cream in study 2.
Conclusion: In 2 well-controlled phase 3 studies, both imiquimod 2.5% and 3.75%
creams were more effective than vehicle when administered daily for up to 8 weeks
to treat EGW. Imiquimod 3.75% was most effective in terms of complete and partial
clearance rates.
Conclusion: In 2 well-controlled phase 3 studies, imiquimod 3.75% cream was
significantly more effective than vehicle cream in both sexes when administered
daily for up to 8 weeks to treat EGW. Efficacy rates were greater in females with
imiquimod 3.57% and 2.5% creams, but the lower concentration was only
significantly more effective than vehicle in 1 study.
Sponsored 100% by Medicis, a division of Valeant Pharmaceuticals.
Sponsored 100% by Medicis, a division of Valeant Pharmaceuticals.
AB46
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8050
P8624
Indeterminate histiocytosis
Andrew John, MD, University of Oklahoma Dermatology, Oklahoma City, OK,
United States
Case presentation of a 60-year-old white male who presented with a 6-month history
of a generalized pruritic papulonodular eruption and also complained of shortness
of breath and cough. Biopsy of the skin was consistent with a histiocytic
proliferation. Immunohistochemistry further categorized the proliferation as
CD1a positive and S100 and langerin negative histiocytosis. There have been very
few recently reported cases with similar immunophenotypes labeled as S100
negative indeterminate cell histiocytoses. Unlike these previous cases, this patient
also presented with pulmonary involvement and bronchoscopy and biopsy was
performed. The pulmonary immunophenotype showed S100 and CD1a positivity,
unlike the findings on cutaneous biopsy. These findings are consistent with
indeterminate cell histiocytosis, although pulmonary ICH has not been previously
reported to our knowledge. The variable expression of S100 based on the involved
organ system makes this case unique as well as the possibility that this represents an
unusual presentation of histiocytosis not previously reported.
Interesting cases from Stony Brook University department of dermatology
Tara Kaufmann, MD, SUNY Stony Brook, East Setauket, NY, United States; David
Silverstein, MD, SUNY Stony Brook, East Setauket, NY, United States
Stony Brook University Hospital is the only tertiary care medical center in Suffolk
County, NY. We amass interesting cases from our inpatient service and outpatient
clinics. We will present 4 cases focusing on cutaneous conditions that could easily
present to any dermatology office. The first is a case of extensive disseminated
superficial porokeratosis with the most severe lesions on the covered buttocks
region. The patient has failed numerous topical treatments, photodynamic therapy,
acitretin, isotretinoin, peel solutions, liquid nitrogen, and ablative laser. The second
is a case of vulvar syringomas that presented as vulvar pruritus. The third case is
multiple facial miliary osteoma cutis in a patient that previously took bisphosphonates for osteoporosis. The final case focuses on bullous lupus as the presenting
sign of systemic lupus erythematosus.
Commercial support: None identified.
Commercial support: None identified.
P7588
Innovative treatment option for moderate to severe generalized psoriasis
using 308-nm excimer laser, clobetasol spray, and calcitriol ointment
Maya Debbaneh, University of California, Irvine, San Francisco, CA, United
States; Argentina Leon, MD, University of California, San Francisco, San
Francisco, CA, United States; Daniel Butler, University of Arizona College of
Medicine, San Francisco, CA, United States; Ethan Levin, MD, University of
California, San Francisco, San Francisco, CA, United States; John Koo, MD,
University of California, San Francisco, San Francisco, CA, United States; Monica
Huynh, Chicago College of Osteopathic Medicine, San Francisco, CA, United
States; Rishu Gupta, University of Southern California, San Francisco, CA, United
States
Background: Excimer laser (308-nm) phototherapy is a very effective treatment for
localized plaque psoriasis because it can deliver supraerythmogenic doses of UVB to
psoriatic plaques. In contrast to traditional UVB therapy, excimer laser treatment has
the added benefit of sparing uninvolved skin. While excimer laser therapy alone is
highly effective for localized psoriasis, the use of laser in combination with
clobetasol spray and vectical ointment has not been studied. Further, this combination therapy allows for treatment of moderated-to-severe generalized psoriasis
without the potential risk of some systemic therapies, such as infection or
malignancy.
Objective: This study evaluates whether the combination of the excimer Laser
(PhotoMedex XTRAC Velocity 700 Laser), clobetasol (Clobex) spray, and calcitriol
(Vectical) ointment can treat moderate to severe generalized plaque-type psoriasis
without exposing the patient to the risks associated with systemic therapies.
Methods: This 12-week study includes patients with confluent plaque-type psoriasis
involving [10% but \30% body surface area. During period 1 (Week 1 e Week 4),
patients receive twice-weekly excimer laser treatment along with twice-daily
clobetasol spray. During period 2 (Week 5 e Week 8), patients receive twice-daily
calcitriol ointment. Laser treatments are continued twice weekly until week 6 and
then as needed thereafter (only if \75% improvement in Psoriasis Area and Severity
Index [PASI] score). During period 3 (Week 9 e Week 12), patients apply both
clobetasol and calcitriol ointment twice daily. The primary endpoint measured was
the percentage of patients achieving PASI 75.
Results: Of the 21 patients enrolled in the study, 71.4% (15/21) achieved PASI 75 by
week 12 of treatment. The most common side effects were itching, burning and
blistering, which were generally well tolerated. One patient discontinued treatment
because of these side effects.
P7575
Juxtaarticular cutaneous hemangiolymphangioma
Michael Wolz, MD, JD, Mayo Clinic, Department of Dermatology, Rochester, MN,
United States; Mark Pittelkow, MD, Mayo Clinic, Department of Dermatology,
Rochester, MN, United States; Michael Camilleri, MD, Mayo Clinic, Department of
Dermatology, Rochester, MN, United States
Conclusion: The combination of excimer laser treatments with clobetasol spray and
calcitriol ointment can be an effective and safe treatment for patients with moderate
to severe generalized psoriasis in those with [10% but \30% body surface area and
confluent plaques.
We propose juxtaarticular cutaneous hemangiolymphangioma (JACHALA) as a
distinctive but rare variant of acquired hemangiolymphangioma of skin. A 71-yearold white woman presented with progressive, articular swelling, and patchy redorange discoloration overlying the right shoulder. A shoulder radiograph showed
advanced degenerative arthritis of right shoulder with chronic rotator cuff
arthropathy consistent with Milwaukee shoulder. The patient had a history of
rheumatoid arthritis, lupus erythematosus and nephrogenic systemic fibrosis related
to gadolinium exposure. Histopathologic examination revealed atypical dermal
vascular proliferation, which was positive for CD31, CD34, as well as FLI-1 and D240 and was negative for HHV-8. An iron stain revealed hemosiderin deposition.
Clinicopathologic correlation yielded a diagnosis of cutaneous hemangiolymphangioma in the setting of chronic inflammatory joint disease. Treatment of the
monoarthropathy led to spontaneous resolution of the hemangiolymphangioma.
JACHALA occurs in skin overlying chronic monoarticular arthritis or joint infection.
It differs from acquired progressive lymphangioma in its clinical features and
pathology. This reactive dermal vasculoproliferative disorder has not been previously highlighted in the literature. Recognition of this distinctive entity is important
to avoid confusion with other benign or malignant vascular proliferative diseases of
the skin.
Sponsored by PhotoMedex.
Commercial support: None identified.
Limitations: This study had a small sample size and lacked a control group.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB47
P7827
P8464
Langerhans cell histiocytosis and hematologic malignancy: A Mayo Clinic
experience
Rie Takahashi, PhD, Mayo Clinic, Rochester, MN, United States; Mark Pittelkow,
MD, Mayo Clinic, Rochester, MN, United States
Malignant fibrous histiocytoma: An evaluation of what lies beneath
Tracie LeBleu Pearson, MD, Louisiana State University, Baton Rouge, LA,
Department of Internal Medicine, Baton Rouge, LA, United States; William
Steffes Jr, MD, University of Florida, Department of Dermatology, Gainesville, FL,
United States
Background: The goal of this study was to identify patients who were diagnosed
with Langerhans cell histiocytosis (LCH) and determine the incidence of patients
who had concurrent hematologic malignancy. LCH is a rare, clonal proliferative
disorder of Langerhans cells in affected organs, such as bone, lung, skin/mucous
membranes, hypothalamus/posterior pituitary gland, lymph nodes, liver, and
various soft tissues supported by clinical symptoms. The course of LCH ranges
from systemic, fulminant disease to localized symptoms that can be cured by
surgical removal. Because of the varied clinical course of LCH, there have been
efforts to distinguish high-risk patients and predict disease progression based on
organ system involvement. Previous studies have reported worse prognosis with
involvement of ‘‘risk organs,’’ such as the hematopoietic system; however, the
incidence of hematologic malignancy in LCH patients is unknown.
Methods: A previous study at Mayo Clinic identified 314 patients with LCH. Similarly,
we conducted a computer-based search for LCH and hematologic malignancies.
Diagnoses were confirmed based on biopsy reports.
Results: We identified 58 Mayo Clinic patient records with a final diagnosis of LCH
(or equivalent term) and hematologic malignancy. Review of paper and electronic
medical records confirmed 19 of 58 patients had biopsy-proven LCH. Of the 19 LCH
patients, 13 also had biopsy-proven hematologic malignancy. These hematologic
malignancies included acute myelogenous leukemia, non-Hodgkin and Hodgkin
lymphoma, cutaneous T-cell lymphoma, hairy cell leukemia, multiple myeloma, and
chronic myelomonocytic leukemia.
Conclusions: We report a significant association of LCH with hematologic
malignancy. These findings suggest possible underlying shared mechanisms of
clonal development of LCH and hematologic malignancies and genomic instability
or immune related mechanisms related to LCH that induce or facilitate leukemogenesis or lymphomagenesis. This study supports the need for regular ongoing
surveillance as well as further investigation of secondary malignancies in patients
with LCH.
Malignant fibrous histiocytoma (MFH) is considered a rare, aggressive sarcoma
commonly involving soft tissue structures, skeletal bone and retroperitoneal
structures. Once thought to be the most common soft tissue sarcoma, reclassification in the early 1990s identified many tumors previously regarded as MFH to not
meet criteria. Scientific advances, especially in immunohistochemistry, have lead to
this reclassification. This has lead to a drastic decline in the incidence of true MFH.
Now, MFH only comprises \5% of all diagnosed adult soft tissue sarcomas. We
present an 87-year-old man with initial complaint of a tender, bleeding, and rapidly
enlarging nodule involving his scalp. Initial biopsy revealed atypical fibroxanthoma
with osteoclastic giant cells which was treated with Mohs micrographic surgery.
Within weeks after surgical resection, the patient was found to have a recurrence
and numerous satellite nodules. He underwent adjunct radiation treatment without
clinical improvement. At that time, additional biopsies revealed an exuberant
histiocytic reaction with numerous multinucleated giant cells extending into the
subcutaneous fat consistent with a diagnosis of MFH. We present a rare clinical
diagnosis with new diagnostic criteria in the past 5 years. MFH is often confused
with and misdiagnosed as atypical fibroxanthoma (AFX), similar to our case. These 2
entities both illustrate pleomorphic spindle cells and nonspecific clinical presentations. In contrast to AFX, MFH has an aggressive clinical behavior and
commonly involves the deep dermis and subcutaneous layers. Advances in
immunohistochemistry are also very helpful in distinguishing MFH from AFX and
other differential diagnoses. Important stains include S-100, cytokeratin, and CD34
to differentiate from desmoplastic melanoma, spindle cell squamous cell carcinoma,
and leiomyosarcoma, respectfully. Also, recent literature supports the use of CD74
staining to distinguish MFH from AFX, a sometimes challenging feat.
Commercial support: None identified.
Commercial support: None identified.
P7794
P8134
Metastatic meningioma of the scalp: Case report and detailed discussion
Dhaval G. Bhanusali, MD, St. Luke’s-Roosevelt Hospital, New York, NY, United
States; Candrice R. Heath, MD, St. Luke’s-Roosevelt Hospital, New York, NY,
United States; Sheryl R. Miller, MD, St. Luke’s-Roosevelt Hospital, New York, NY,
United States
Meningiomas are the most common, benign, intracranial tumor in adults, generally
presenting as slow growing, expanding intracranial lesions. Rarely, meningiomas
can exhibit malignant potential and present as an extracranial, soft tissue mass
through extension or even as a primary extracranial cutaneous neoplasm. Although
uncommonly encountered by dermatologists, it is crucial for the practitioner to have
a broad differential when approaching scalp lesions. We present a rare case of a 68year-old female with biopsy proven metastatic meningioma to the scalp, 10 years
after initial resection of her primary tumor. This case provides an opportunity to
review the literature regarding a uncommon condition that may be seen in clinical
practice.
Commercial support: None identified.
AB48
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8221
P8291
Methotrexate-induced skin necrosis in a patient with atopic dermatitis
Jonathan Levy, MD, Jonathan Levy, Edmonton, Canada; Parbeer Grewal, MD,
University of Alberta, Edmonton, Canada; Vimal Prajapati, MD, University of
Alberta, Edmonton, Canada
Introduction: Methotrexate (MTX) is widely used in the treatment of psoriasis and
other autoimmune conditions, but less commonly in atopic dermatitis. Adverse
effects are typically dose-related and include myelosuppression, liver and renal
toxicity, gastrointestinal tract erosions/ulcerations and cutaneous ulceration. The
term ‘‘MTX-induced necrolysis’’ was first coined in 1983 by Reed and Sober. In total,
including this case, 48 cases have been reported in the English literature.
Mucocutaneous manifestations of AL type systemic amyloidosis
Jose Miguel Lera, MD, University Clinic of Navarra, Pamplona (Navarra), Spain;
Isabel Bernad, MD, University Clinic of Navarra, Pamplona (Navarra), Spain;
Isabel Irarrazaval, MD, University Clinic of Navarra, Pamplona (Navarra), Spain;
Maider Pretel, MD, PhD, University Clinic of Navarra, Pamplona (Navarra), Spain;
Marta Ivars, MD, University Clinic of Navarra, Pamplona (Navarra), Spain
Case report: A 56-year-old white woman being treated with MTX for atopic
dermatitis presented with a 1-week history of fever, neutropenia, oral ulceration,
and a pruritic, ulcerative skin eruption. Examination revealed a generalized eruption
consisting of multiple discrete and coalescing crusted erosions and ulcerations on a
background of lichenification. The patient had been instructed to take MTX 22.5 mg
orally divided into 3 doses taken every 12 hours once weekly; however, she
mistakenly took methotrexate 7.5 mg every 12 hours for 7 days. Histopathologic
evaluation of one of the lesions demonstrated a sharply demarcated area of
epidermal ulceration and necrosis. Staining for herpes simplex virus (HSV)-1 and
HSV-2 were both negative.
Discussion: This is the first case report of MTX-induced skin necrosis in a patient
being treated for atopic dermatitis. MTX-induced skin necrosis is a rare finding given
that it generally only occurs when much higher doses than advised for dermatologic
conditions are given. While psoriasis is the most frequent dermatologic disease
treated with MTX, and thus the most common with this adverse effect, MTX-induced
skin necrosis has also been reported in patients with rheumatoid arthritis, cutaneous
T-cell lymphoma, ankylosing spondylitis, acute lymphoblastic leukemia, Burkitt
lymphoma, and choriocarcinoma. An important differential diagnosis to consider in
this case includes eczema herpeticum, which can have similar cutaneous manifestations, but would not present with pancytopenia. Our patient was treated with a
5-day course of leucovorin and topical corticosteroids and mupirocin with eventual
healing of all lesions.
Commercial support: None identified.
Introduction: AL type or ‘‘light chains’’ systemic amyloidosis is an uncommon
disease characterized by the amyloid deposit in multiple organs. Mucocutaneous
manifestations are observed in 40 percent of cases, according to other publications.
We review all cases of AL type systemic amyloidosis reported in our hospital in last
years, specially those affecting mucosa and skin.
Methods: We evaluate 39 cases of AL type systemic amyloidosis, histologically
diagnosed in our medical center in last 12 years and we describe the mucocutaneous
manifestations found in them.
Results: Twenty-one patients of the total number of cases were women (54%) and 18
men (46%), with an average age of 64.3 years old. Concerning the origin of
amyloidosis, 14 cases (36%) had a multiple myeloma associated. In all other cases
(64%) a diagnosis of primary AL type amyloidosis was made. Seven patients (23%)
showed an involvement of the oral mucosa (macroglossia, lingual papillomatosis,
oral wounds and gingival hyperplasia) and just 5 cases (12.8%) had cutaneous
manifestations (2 cases with ‘‘raccoon eyes,’’ palmar and facial yellow papules in a
patient, and a case of alopecia; all patients had purpuric lesions on their skin).
‘‘Shoulder pad’’ sign was only observed in 1 patient. In relation to abdominal fat
biopsy, it was made in 16 cases, been subsequently confirmed by the detection of
amyloid deposit in other tissues. From all these 16 cases, only 5 of them (31%)
showed amyloid deposit in skin.
Conclusions: AL type systemic amiloidosis is a rare entity characterized by detection
of amyloid deposits in many tissues. It has been described a strong relationship with
blood dyscrasias such as multiple myeloma, Waldestr€
om disease, and lymphomas.
When no other diseases are associated, a diagnosis of primary sistemic amyloidosis is
made. The incidence of mucocutaneous manifestations is variable. In our study, we
show a low incidence of skin (13%) and oral mucosa (23%) involvement.
Concerning the cutaneous biopsy findings, we find a low sensitivity (31%) in our
study, unlike other reported publications.
Commercial support: None identified.
P8623
Mucosal predominal linear immunoglobulin A bullous dermatosis
Kemunto Mokaya, MD, MHS, University of California in San Francisco (UCSF), San
Francisco, CA, United States; Rachel Kornik, MD, University of California, San
Francisco (UCSF), San Francisco, CA, United States
Background: Linear IgA bullous dermatosis (LABD) is a rare, autoimmune mucocutaneous blistering disease characterized by linear deposits of IgA at the dermoepidermal junction.
P8449
Mid-dermal elastolysis: A case report and review of the literature
Wenjun Zhou, Medical University of South Carolina College of Medicine,
Charleston, SC, United States; Bruce Thiers, MD, Medical University of South
Carolina Department of Dermatology and Dermatologic Surgery, Charleston, SC,
United States; Kathryn Dempsey, MD, Medical University of South Carolina
Department of Dermatology and Dermatologic Surgery, Charleston, SC, United
States
Mid-dermal elastolysis (MDE) is a rare, acquired disorder of elastic tissue that
typically presents as discrete patches of fine wrinkling over the trunk, neck, and
arms or as perifollicular papules in the same distribution. Histologically, the lesions
show a selective loss of elastic tissue limited to the mid-dermis. We report a case of a
46-year-old white woman who presented with a 20-year history of progressive,
asymptomatic wrinkling of her arms, neck, and back. The physical examination
revealed diffuse, fine wrinkling of her proximal arms and lateral neck, perifollicular
papules on her central back, and soft, flesh-colored papules ranging between 1 and 5
mm on the lateral aspect of her back. Our differential diagnoses included
anetoderma, mid-dermal elastolysis, and pseudoxanthoma elasticum. Biopsies
were taken from the fine wrinkling on her arm and a soft papule from the lateral
back. Modified Masson trichrome stain demonstrated a decrease in elastic fibers in
the mid-dermis with preservation of elastic fibers in the superficial and deep dermis,
consistent with MDE. This case report highlights a relatively rare condition.
Approximately 80 cases of MDE have been described in the literature to date.
Although our patient had the classic findings of MDE, the presentation of soft, fleshcolored papules is atypical. The management of MDE remains challenging and we
review the treatment options.
Commercial support: None identified.
Case report: A 70-year-old woman was started on vancomycin for presumed
cellulitis. Three days later, she reported sudden burning pain of her mouth and
genitalia accompanied by oral swelling and shortness of breath. She then developed
blisters in her mouth and groin. The physical examination revealed tense, 3- to 5-mm
fluid-filled vesicles on the tongue and labial mucosa extending into the posterior
oropharynx. A genital examination revealed tense vesicles on the bilateral labia
majora, inguinal creases, and proximal inner thighs arranged in a linear pattern.
Nikolsky and AsboeeHansen signs were negative. A punch biopsy revealed
supepidermal clefts containing neutrophils and leukocytoclastic debris. Direct
immunofluorescence (DIF) revealed deposition of IgA in a linear pattern along the
junctional zone. Stains for IgG, IgM, and C3 were negative. The vancomycin was
discontinued, and she was started on prednisone (1 mg/kg) given extensive
inflammation. Her condition resolved within 7 days.
Discussion: Although often idiopathic, LABD has been associated with infection,
malignancy, autoimmune diseases, gastrointestinal disorders, and various drugs.
Vancomycin is most commonly implicated in drug-induced LABD. Other less
common agents include penicillins, cephalosporins, NSAIDS, ace-inhibitors,
phenytoin, lithium, IL-2, and many others. Drug-induced LABD typically develops
1 to 15 days after starting the offending agent. The eruption presents as tense
vesicles and bullae on the trunk, extremities, genitalia and oropharynx; arranged in a
linear or arcuate pattern. Rarely, the mucosa is the initial or predominant site of
involvement of LABD, as in the case of our patient. To our knowledge, this is the first
case of mucosal predominant vancomycin-induced LABD reported. While selflimited, drug-induced LABD may carry significant morbidity due to inflammation
and scarring of involved mucosal surfaces; and a multidisciplinary management
approach can prevent serious sequelae. Dapsone is the first-line therapy followed by
sulfonamide drugs, such as sulfapyridine and sulphamethoxypyridazine. If these fail,
corticosteroids or other immunosuppressive agents such as mycophenolic acid,
colchicine, cyclophosphamide, cyclosporine, or antimicrobial agents may be tried.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB49
P7996
P8179
Multimodal evaluation of the efficacy of a shampoo treatment for chronic
recurrent seborrheic dermatitis and the value of a maintenance treatment
Virginie Turlier, MS, Centre de Recherche sur la Peau Pierre Fabre, Toulouse
cedex 3, France; Anne-Marie Schmitt, MD, Centre de Recherche sur la Peau
Pierre Fabre, Toulouse cedex 3, France; Cecile Viode, PhD, Centre de Recherche
sur la Peau Pierre Fabre, Toulouse Cedex 3, France; Daniel Redoules, PhD, Centre
de Recherche sur la Peau Pierre Fabre, Toulouse cedex 3, France; Valerie
Mengeaud, PhD, Centre de Recherche sur la Peau Pierre Fabre, Toulouse cedex 3,
France; Vincent Durosier, MD, Pierre Fabre Dermo Cosmetique, Lavaur cedex,
France
Neutrophilic dermatosis: A unique presentation
Dawn Caruana, MD, NHS Lanarkshire, Airdrie, United Kingdom; Frances
Gallagher, MBBCh, NHS Lanarkshire, Airdrie, United Kingdom; Giri Raj,
MBChB, NHS Lanarkshire, Airdrie, United Kingdom; Goutam Dawn, MBBS, MD,
NHS Lanarkshire, Airdrie, United Kingdom; Janika Borg, MD, NHS Lanarkshire,
Airdrie, United Kingdom
Background: Relapses are always observed after stopping scalp antidandruff
treatment. A shampoo formulation with cyclopiroxolamine, zinc, pirythione betaglycyrrhetinic acid was developed to treat dandruff/seborrheic dermatitis (SD). We
wanted to evaluate the effect of a short attack phase on the improvement of SD, and
a maintenance phase in the prevention of recurrences, and also to highlight
relationships between clinical, biochemical, and microbiological parameters
involved in SD.
Methods: Sixty-seven subjects with SD, presenting with erythema and itching were
included in this 2-phase study. Phase 1: a common attack phase of 2 weeks, followed
by phase 2, a comparative, parallel group phase of 8 weeks, subjects being
randomized into 2 groups: maintenance or discontinuation (‘‘stop’’). The shampoo
was used thrice a week during phase 1, then once a week alternating with a neutral
shampoo during phase 2 in the maintenance group only, the group ‘‘stop’’ using only
the neutral shampoo. Efficacy was assessed: clinically: Overall Clinical Dandruff
Score, erythema, overall efficacy, self-assessment of dandruff, discomfort, itching:
biochemically and microbiologically (from scale samples analyzed by qPCR or
ELISA): Malassezia (restricta and globosa), cohesion proteins (plakoglobins),
inflammation (IL8, IL1RA/IL1) and pruritus (histamine, capthepsin S) markers.
Results: Phase 1: highly significant improvement in SD (P\.0001) with a decrease in
clinical signs of SD as well as Malassezia species, cohesion proteins, inflammation
and pruritus markers. Phase 2: improvement was maintained in the ‘‘maintenance’’
group, while in the ‘‘stop’’ group, it regressed significantly, with a significant
intergroup difference in favor of the ‘‘maintenance’’ group. A systematic positive
relationship (P \.05) was found between the main clinical signs of SD (dandruff,
itching, and erythema) and the following biomarkers: Malassezia populations,
histamine levels and IL1RA/IL1 ratio. The overall efficacy was negatively related to
these biomarkers.
Conclusion: The effectiveness of the shampoo treatment was demonstrated
clinically, biochemically, and microbiologically, after a short attack phase of only 2
weeks. These improvements persisted significantly only in the maintenance group.
The correlations observed between clinical signs and biomarkers provide clues to
explain the resolution of SD and confirm the usefulness of a maintenance therapy
also shown by conventional clinical measures.
A 68-year-old woman presented with a 2-month history of a tender annular eruption
on the plantar aspect of both feet. There was no accompanying constitutional
disturbance and no evidence to suggest occult malignancy or other systemic
inflammatory disorders. Histologic analysis of skin biopsies from both soles revealed
a prominent dermal neutrophilic infiltrate with no evidence of vasculitis, consistent
with neutrophilic dermatosis. Five years previously, the patient had a similarly
striking annular, nodular eruption affecting the palmar and dorsal aspects of the
right hand, elbow, and inner thighs. The initial clinical appearance mimicked
nodular granuloma annulare; however, histology favored neutrophilic dermatosis.
The thigh eruption had resolved spontaneously and the elbow eruption cleared with
the use of super potent topical steroids and tacrolimus 0.1% ointment.
Unfortunately, the hand nodules had grown more uncomfortable with progressive
ulceration. Despite the patient’s initial reluctance for systemic therapy, she later
agreed for initiation of dapsone treatment. This was started at a dose of 50 mg daily
with resultant clearance over a 12-month period. In view of this previous clinical
response, dapsone was reinstituted in an attempt to clear the sole eruption. Yet
again, our patient achieved complete clearance with dapsone monotherapy over the
following 4 months and she is currently in remission on a low maintenance dose of
50 mg twice weekly. Neutrophilic dermatosis of the hands (NDH) is a rare
presentation in the spectrum of neutrophilic dermatoses, characterised by the
recruitment of a polymorphonuclear leucocyte-rich infiltrate in the dermis. It may
represent a subset of acute febrile neutrophilic dermatosis or Sweet syndrome;
however, it lacks the systemic symptoms synonymous with the latter. NDH is
characterised by tender erythematous plaques, pustules, bullae or nodules in
addition to ulcerating and vegetating lesions. The initial eruption usually presents on
the dorsum of the hands however, as evidenced by small case series and reports, it
has been reported to spread to the palmar aspect of the hands, cheek, lips, back,
upper gingivae, arms and legs. This case illustrates a unique presentation of NDH
involving the plantar aspects of the feet. Vasculitis is a not a constant feature in NDH,
but its absence in our case makes erythema elevatum diutinum a less likely
diagnosis.
Commercial support: None identified.
Sponsored 100% by Pierre Fabre Dermo-Cosmetique.
P7873
Multinucleated cell angiohistiocytoma: A case report and literature review
Tara Kaufmann, MD, SUNY Stony Brook, East Setauket, NY, United States;
Olapeju Olasokan, SUNY Stony Brook, East Setauket, NY, United States
Multinucleated cell angiohistiocytoma (MCAH) is a rare benign skin condition
usually affecting middle age to elderly females. We report a case of a 61-year-old
white female with no family history of skin cancer that presented with a 1-year
history of multiple pink nonpruritic plaques on the right second digit and dorsum of
bilateral hands. Multiple erythematous to violaceous papules and plaques were
visualized on examination. Biopsy of the right dorsum of hand revealed an increased
number of dilated blood vessels, multinucleated cells and thickened collagen
bundles with proliferation of fibroblast small blood vessels and thickened collagen
bundles arranged in a linear fashion. The diagnosis was confirmed to be a
multinucleated cell angiohistiocytoma (MCAH). We reviewed the literature and
looked specifically at estrogen’s role in the condition, because MCAH predominately
affects females.
Nodular blaschkoid eruption in a healthy 28-year-old woman
Jason Michaels, MD, Mayo Clinic, Scottsdale, AZ, United States; Amanda Pickert,
MD, Mayo Clinic, Scottsdale, AZ, United States; David DiCaudo, MD, Mayo Clinic,
Scottsdale, AZ, United States
A 28-year-old woman presented with an asymptomatic unilateral papulonodular
blaschkoid eruption of the left volar forearm that developed over 6 months.
Individual lesions consisted of blue-purple papules and deep-seated nodules
measuring 5-15 mm in diameter. The patient was otherwise in good health and a
preceding illness was not identified. Her family history revealed an uncle with HandSchuller-Christian disease that occurred at 4 years old and remitted by age 5. Before
appearing in our clinic, 4 skin biops specimens were obtained that revealed a
pandermal infiltrate of CD68+ oval histiocytes with homogenous-appearing eosinophilic cytoplasm consistent with reticulohistiocytoma. Tissue sent for fungal
culture showed no growth after 4 weeks. Because of concerns of multicentric
reticulohistiocytosis, a PET scan was performed and was without abnormalities. In
addition, radiographs of the hands, feet, ankles, and wrists were normal in
appearance. The results of a complete blood count and comprehensive metabolic
panel were within normal limits. Skin biopsy of a representative lesion in our clinic
revealed a dense dermal infiltrate of CD68+, factor XIIIa+, S100e, CD1ae histiocytes
with 2-toned granular cytoplasm. These findings, and the results of the previous
studies, allowed us to render the diagnosis of multiple reticulohistiocytosis. The
reticulohistiocytoses are a group of rare, noneLangerhans cell histiocytoses. Three
clinical patterns exist: solitary reticulohistiocytoma, multicentric reticulohistiocytosis, and multiple reticulohistiocytosis. Multiple cutaneous reticulohistiocytosis
without systemic involvement is exceedingly rare, with only 10 cases reported in the
literature to date. What makes the present case exceptional is the striking blaschkoid
distribution of the lesions, a phenomenon described in a single published case
associated with lichen striatus. The family history of Langerhans cell histiocytosis
(LCH) is intriguing but we cannot immediately link it with our patient’s non-LCH
eruption. At present, there are no defined criteria for surveillance of patients with
multiple cutaneous reticulohistiocytosis. Because of the rarity of the condition, it is
only somewhat reassuring that none of the reported cases have progressed to
systemic involvement. Optimal follow-up is of paramount importance, with careful
focus on the development of arthralgias or malignancy that might herald the onset of
multicentric histiocytosis.
Commercial support: None identified.
Commercial support: None identified.
P8615
AB50
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8588
P8599
Nutritional deficiency in a fortified nation
Matthew Palmer, MD, Geisinger Medical Center, Danville, PA, United States;
Victor Marks, MD, Geisinger Medical Center, Danville, PA, United States
Background: Nutritional deficiency is most often caused by the inadequate intake or
absorption of essential dietary elements. The clinical manifestations of nutritional
deficiency are diverse and subtle at times. Scurvy is characterized by perifollicular
petechiae, hyperkeratosis of the hair follicles, cork screw hairs, edema, purpura,
hemorrhagic gingivitis, and delayed wound healing.
Case report: A 30-year-old otherwise healthy woman presented to outpatient clinic
with 2 years of chronic asymptomatic erythema and scaling of the nose. She denied
any past medical problems, associated symptoms, or medications. Complete review
of systems was negative. Prior attempted treatments with mild topical steroids and
emollients had provided no improvement. On exam she had a 2-cm erythematous,
atrophic plaque with telangiectasia on the nasal tip. Focal gingival hyperplasia and
poor dentition were also noted. Biopsy of nasal tip demonstrated telangiectasia and
perifolliculitis. Biopsy of the gingiva demonstrated gingival hyperplasia. Laboratory
evaluation was significant for vitamin C (ascorbic acid), B2 (riboflavin), and B3
(niacin) at undetectable levels. Basic metabolic panel and complete blood count
were unremarkable. Further questioning regarding her diet revealed that she
completely subsided on fast food. Staple meals consisted of ‘‘hamburgers and
chicken fingers’’ and included no fruits or vegetables. After her condition failed to
improve with standard education on diet modifications, a referral to a nutritionist
was made. Eventually, she was lost to follow-up.
Pacinioma: An unusual digital tumor. Case report
Dalia Rodriguez Acosta, MD, Instituto Nacional de Ciencias Medicas y Nutrici
on
‘‘Dr. Salvadar Zubiran,’’ Mexico City, Mexico; Jose Manuel Diaz Gonzalez, MD,
Instituto Nacional de Ciencias Medicas y Nutrici
on ‘‘Dr. Salvadar Zubiran,’’
Mexico City, Mexico; Judith Dominguez-Cherit, MD, Instituto Nacional de
Ciencias Medicas y Nutrici
on ‘‘Dr. Salvadar Zubiran,’’ Mexico DF, Mexico; Julio
Jasso Olivares, MD, Instituto Nacional de Ciencias Medicas y Nutrici
on ‘‘Dr.
Salvadar Zubiran,’’ Mexico City, Mexico; Linda Garcia Hidalgo, MD, Mexico DF,
Mexico
Pacinian corpuscles are mechanical receptors usually located in the palmar and
plantar aponeurosis. In the subcutaneous tissues of the volar surface of the proximal
phalanges, they are normally found adjacent to a nerve or tendon. Hypertrophy and
hyperplasia of pacinian corpuscles in the hand are very rare, with only 34 cases
previously published. We describe a case in a 50-year-old housewife who
complained of progressive tenderness and pain during prehension with the right
hand.A palmar tenosynovial cyst of the index finger was suspected, but we
discovered a small mass along the fourth collateral nerve, consisting of an unusual
grape-like structure of white granules. Postsurgical evolution was uneventful. The
biopsy shown within the adipose tissue several enlarged pacinian corpuscles, some
corpuscles measured up to 2.5 mm in their long axis (normal, 1-1.5 mm on paraffinembedded material). Each corpuscle had a central axis (;15 m in diameter)
surrounded by almost 35-50 lamellae (normal, no more than 15 to 35 lamellae) and
was limited by a fibrous capsule. Immunohistochemical and electronmicroscopic
investigations indicated that the lump replicates the structure of enlarged pacinian
corpuscles and should not be considered as a real tumor, nor connected to
neurofibromatosis. No recurrence was observed after surgical excision. Although
local trauma was encountered in 55% of the reported cases, the pathogenesis of such
a lesion is still speculative.
Discussion: Nutritional deficiencies are most common in underdeveloped regions of
the world. When observed in developed countries, it is most commonly associated
with alcoholism, fad diets, chronic diseases including malignancies, institutionalization, and eating disorders. It is also seen in those with anatomic or physiologic
abnormalities limiting absorption of nutrients including iatrogenic states, such as
gastric bypass patients. In our experience, isolated nutritional deficiencies—for
example, deficient in zinc only—is uncommon, and therefore a thorough evaluation
is required. Our patient only had clinical findings of scurvy yet was found to be
deficient in vitamins B2 and B3 as well.
Commercial support: None identified.
Conclusion: Nutritional deficiency, while uncommon in developed countries, must
still be including when evaluating otherwise healthy patients in the general
dermatology clinic.
Commercial support: None identified.
P8619
Oral mucosal and cutaneous findings in Fanconi’s anemia patients
Silvia Mendez-Flores, MD, Dermatology Department. Instituto Nacional de
Ciencias Medicas y Nutrici
on ‘‘Salvador Zubiran,’’ Mexico D.F., Mexico; Amparo
Hernandez-Salazar, MD, Instituto Nacional de Ciencias Medicas y Nutrici
on,
Mexico D.F., Mexico; Judith Dominguez-Cherith, MD, Instituto Nacional de
Ciencias Medicas y Nutrici
on, Mexico D.F., Mexico; Lilly Esquivel-Pedraza, MD,
Dermatology Department. Instituto Nacional de Ciencias Medicas y Nutrici
on
‘‘Salvador Zubiran,’’ Mexico D.F., Mexico
Background: Fanconi anemia (FA) is a rare autosomal recessive disorder related to
defective caretaker genes that is clinically characterized by congenital malformations, progressive bone marrow failure, and increased incidence of malignancies,
especially acute myeloid leukemia and squamous cell carcinomas of the head and
neck (HNSCCs) and anogenital regions.
Objective: To describe the clinical findings in 2 patients with FA seen in a tertiary
care center in Mexico City, focusing on mouth and skin manifestations.
P7863
Pain associated with lipomas
Leigh Sutton, MD, Scott and White Texas A&M, Temple, TX, United States;
Katherine Fiala, MD, Scott and White Texas A&M, Temple, TX, United States;
Kathleen Nyugen, Scott and White Texas A&M, Temple, TX, United States
Discussion: FA is an inherited condition of chromosomal instability. Prevalence of
oral cancer has been reported in almost 50% of patients. Cancer therapy in such
patient is frequently difficult due to systemic conditions. A very close follow-up
should be made in FA patients, considering the increased incidence of malignancies
observed and the considerably reduced life expectancy in such patients.
Lipomas are common benign tumors that frequently present in the subcutaneous
tissue. They may slowly change in size but are often asymptomatic. However, rarely
patients with lipomas present with associated pain symptoms. Most of these cases
are presented in orthopedic and neurology literature. We report 2 patients whose
pain symptoms significantly improved upon excision of the adjacent lipomas. The
first case is a 70-year-old female who presented with a 13 3 12 mm subcutaneous
nodule on her right postauricular neck. The patient also stated she had severe
episodic aching right ear pain. Brain MRI ordered by neurology was negative.
Pathology of the subcutaneous nodule was consistent with lipoma. The second case
is a 40-year-old female who presented to clinic with a 15 3 15 mm nodule on her
glabella. The second patient also stated she had noticed new onset headaches
occurring in the region near her nodule. Excision was performed and pathology
revealed an intramuscular lipoma. In both cases, the patients’ pain symptoms were
relieved after removal of the lipomas. Previously proposed mechanisms of pain
associated with lipomas include nerve entrapment, mechanical irritation, stretching
of nerve fibers, or increased pressures on soft tissue. Because of the superficial
location of the patients’ lipomas described above, the etiology of pain is likely
caused by pressure on surrounding soft tissues or stretching of nearby nerve fibers.
Although the exact mechanism of associated pain cannot be determined, excision of
lipomas may be a safe and simple treatment for pain symptoms.
Commercial support: None identified.
Commercial support: None identified.
Cases: A 22 year-old man was referred to the oral diseases clinic of the Dermatology
Department at the INCMNSZ. At oral examination, red and white patches affecting
palatal and tongue were detected, and an ulcer in right border of the tongue, which
was diagnosed as squamous cell carcinoma, treated with surgical resection. A 17year-old female patient with FA was examined in May 2013 because of a burning
sensation in the mouth. Xerostomia, atrophy of the mouth mucosa mainly affecting
the dorsum of the tongue, erythemathous candidosis, and angular cheilitis were
seen.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB51
P7663
P8647
Patterns of ambulatory care usage and leading treatments for rosacea
Scott Davis, Wake Forest School of Medicine, Winston-Salem, NC, United States;
Steven Feldman, MD, PhD, Wake Forest School of Medicine, Winston-Salem, NC,
United States
Background: Millions of rosacea sufferers are not being treated, and the reasons they
do not get treatment are not well characterized.
Porokeratotic eccrine nevus
Lourdes Espinosa-Alonzo, MD, Centro Dermatologico ‘‘Dr. Ladislao de la Pascua,’’
Mexico City, Mexico; Alba Posligua, MD, Centro Dermatologico ‘‘Dr. Ladislao de
la Pascua,’’ Mexico City, Mexico; Alfonsina Decamps, MD, Centro Dermatologico
‘‘Dr. Ladislao de la Pascua,’’ Mexico City, Mexico; Gisela Navarrete, MD, Centro
Dermatologico ‘‘Dr. Ladislao de la Pascua,’’ Mexico City, Mexico; Lourdes AlonzoRomero, MD, Centro Dermatologico ‘‘Dr. Ladislao de la Pascua,’’ Mexico City,
Mexico
Introduction: A 25-years old Mexican female, with a 20-year personal history of
‘‘warts.’’ Her skin disease started on her left shoulder spreading later to her fifth
finger of the same hand.
Case report: At physical examination we observed a warty group of papules and
nodules, seated over erythema that had a linear disposition. We made the clinical
diagnosis of systematized inflammatory linear verrucous epidermal nevus. We took a
biopsy of the lesion and the histopathologic study showed a hyperkeratotic
epidermis, plenty cornoid lamella with agranulosis under it, spinous cell edema,
moderate irregular acanthosis and some dyskeratotic cells. In superficial dermis we
observated a moderate lymphohistiocytic infiltrate and the presence of melanin
pigment. With these clinicopathologic findings, we made the definite diagnosis of
porokeratotic eccrine nevus.
Discussion: The porokeratotic eccrine ostial and dermal duct nevus is a rare
hamartoma of the eccrine sweat glands. This condition has 2 clinical appearences:
keratotic depressions on palms and soles with a semblance to comedones or warty
hyperkeratotic papules. The lesions are grouped linearly or patchy, with unilateral
distribution following the lines of Blaschko. There have been case reports of bilateral
distribution. The palmoplantar affection is more common, followed by posterior
thorax, hands and feet, with less frequency of generalized distribution. Usually is
present at birth or develop during childhood, but may occur at adulthood. It remains
stable for a long period of time but sometimes it has regression. It is not associated
with other congenital anomalies. The differential diagnosis for palms and soles
affection must be made with, palmoplantar keratoderma punctata, palmoplantar
porokeratosis, arsenical keratosis and acrokeratoelastoidosis. In the linear variant,
the differential diagnosis should be make with systematized inflammatory linear
verrucous epidermal nevus, linear psoriasis, linear porokeratosis, lichen planus and
striated lichen; must also be distinguished from other congenital or acquired
dermatoses following Blaschko lines. The histopathology is characteristic and makes
the diagnosis of certainty. Treatment options are topical use of calcipotriol,
keratolytic agents, corticosteroids, other modalities include cryotherapy, cauterization, localized surgical excision or laser ablation of CO2.
Objective: To determine the main reasons for visit, providers seen, and treatments
used for rosacea.
Methods: We used data from the National Ambulatory Medical Care Survey for
1993-2010, tabulating the leading reasons for visit, providers seen, and treatments
used in rosacea visits.
Results: There were 1,750,000 visits per year for rosacea. The leading reasons for
visit were other diseases of the skin (25.3%), skin rash (19.6%), and discoloration or
abnormal pigmentation (14.7%). Dermatologists managed 72.4% of visits. The most
common treatments used were topical metronidazole (29.3%), tetracycline (11.0%),
minocycline (8.5%), doxycycline (7.9%), and oral metronidazole (6.9%).
Limitations: Some reasons for visit were too nonspecific to provide good insight on
why the patient made a visit.
Conclusions: Dermatologists manage rosacea most commonly, but primary care
physicians need the proper training to diagnose it correctly. Improved strategies to
reach untreated people with rosacea are needed.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
Commercial support: None identified.
P8671
Porokeratosis with genito-gluteal involvement after bone marrow
transplantation: A case series
Viswanath Reddy Belum, MD, Memorial Sloan-Kettering Cancer Center, New
York, NY, United States; Christiane Querfeld, MD, PhD, Memorial Sloan-Kettering
Cancer Center, New York, NY, United States; Mario E Lacouture, MD, Memorial
Sloan-Kettering Cancer Center, New York, NY, United States; Patricia L
Myskowski, MD, Memorial Sloan-Kettering Cancer Center, New York, NY,
United States
Background: Porokeratosis is an epidermal disorder involving clonal hyperproliferation of keratinocytes that manifests itself through distinct clinicomorphologic
subtypes. The representative lesion is an asymptomatic plaque with a peripheral
hyperkeratotic ridge. Even in the disseminated forms, involvement of the genitogluteal regions is rare. Genito-gluteal distribution has not been reported among BMT
recipients, in whom the disorder itself is an extraordinary finding.
Methods: BMT recipients with suspicious skin lesions on follow-up were evaluated
in the dermatology service at Memorial Sloan-Kettering Cancer Center. Between the
years 1996 and 2012, porokeratosis involving the genito-gluteal regions was noted in
eight patients with or without disseminated disease. The diagnosis was confirmed
by histopathology; all patients were effectively treated and are on regular
dermatology follow-up.
Results: All 8 patients’ biopsies had the characteristic unifying feature of
porokeratotic disorders, the ‘‘cornoid lamella,’’ which appears as an angulated
column of parakeratotic cells within an epidermal invagination. None of the lesions
demonstrated malignant transformation and all were successfully treated with
cryotherapy or shave excisions. Seven patients are on routine follow-up with no
current evidence of malignant degeneration.
P8687
Prescriptive profile of treatment of patients with actinic keratosis
Marco Ant^
onio Oliveira, MD, PhD, AC Camargo C^ancer Center, S~ao Paulo, Brazil;
Samanta Nunes, MD, Samanta Nunes, S~ao Paulo, Brazil
Conclusion: Our single-institution series suggests the role of aberrant immunosurveillance mechanisms in BMT recipients. The study also underscores the importance
of long-term follow-up in detecting and effectively treating seemingly innocuous
lesions that have a potential for malignant transformation. In addition, vigilant
monitoring of covered areas in such patients is warranted.
Actinic keratosis is an intraepithelial manifestation of abnormal proliferation of
keratinocytes which occurs in fair-skinned patients exposed chronically to the
sunlight. Although it has high potential for progression to skin carcinomas, the
prevalence and management of actinic keratosis is little known in Brazil. We aim to
qualify which topical treatment for actinic keratosis is performed by dermatologists.
We conducted a health observational survey in which 10 dermatologists reported
treatments proposed for lesions of actinic keratosis. Of all patients treated (4993),
6% were diagnosed with actinic keratosis. The topical treatments were used in 29
percent of the cases in which imiquimod and 5-FU were the most prescribed. It was
observed that there was a preference for the use of topical treatments to the
detriment of other procedures. The practicality and location of the lesions were
decisive criteria for the choice of treatment. In conclusion, the prevalence of actinic
keratosis was 6%; there is a preference for the use of topical treatments for localized
lesions on the scalp and actinic cheilitis, being the most important criteria for the
selection: convenience and location of lesions.
Commercial support: None identified.
Commercial support: None identified.
AB52
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8104
P7835
Progressive nodular histiocytosis: Successful treatment with methotrexate
Hari Reddy, MBBS, University Hospital of North Durham, Durham, United
Kingdom; Robert Ellis, MD, University Hospital of North Durham, Durham,
United Kingdom; Sivakumar Natarajan, MD, The James Cook University Hospital,
Middlesbrough, United Kingdom
Pulsed intravenous immunoglobulin therapy in refractory ulcerated
livedoid vasculopathy: Seven cases and a literature review
So Young Yoon, MD, Department of Dermatology, Seoul National University
Boramae Hospital, Laboratory of Cutaneous Aging and Hair Research, Biomedical
Research Institute, Seoul, South Korea; Eun Jee Kim, MD, Department of
Dermatology, Seoul National University Boramae Hospital, Laboratory of
Cutaneous Aging and Hair Research, Biomedical Research Institute, Seoul,
South Korea; Hyun Sun Park, MD, Department of Dermatology, Seoul National
University Boramae Hospital, Laboratory of Cutaneous Aging and Hair Research,
Biomedical Research Institute, Seoul, South Korea; Hyun-Sun Yoon, MD, PhD,
Department of Dermatology, Seoul National University Boramae Hospital,
Laboratory of Cutaneous Aging and Hair Research, Biomedical Research
Institute, Seoul, South Korea; Jin Yong Kim, MD, Department of Dermatology,
Seoul National University Boramae Hospital, Laboratory of Cutaneous Aging and
Hair Research, Biomedical Research Institute, Seoul, South Korea; Sihyeok Jang,
MD, Department of Dermatology, Seoul National University Boramae Hospital,
Laboratory of Cutaneous Aging and Hair Research, Biomedical Research Institute,
Seoul, South Korea; Soyun Cho, MD, PhD, Department of Dermatology, Seoul
National University Boramae Hospital, Laboratory of Cutaneous Aging and Hair
Research, Biomedical Research Institute, Seoul, South Korea
A 53-year-old female presented in February 2006 with multiple nodules over her
neck. These gradual increased in size and number; eventually spreading to her trunk,
face, oral cavity, and conjunctivae. The nodules were occasionally itchy and tender.
The patient had a history of depression, anxiety, and chronic ordinary urticaria.
Medication included propranolol and cetirizine. Physical examination revealed
numerous firm, flesh to yellow/orange colored papules and nodules over her neck,
trunk, and face. Similar, smaller lesions were seen within the mouth, upon the hard
palate and conjunctivae. Routine hematology, biochemistry, and lipid profile were
normal; myeloma screen was negative. Chest radiograph and MRI of the head and
neck were unremarkable. Examination by ENT team revealed nodules within the
larynx. Histopathologic examination of multiple incisional biopsies identified
nodules within dermis containing spindle, foamy, and multinucleated giant cells.
The epidermis was normal. Immunologic assessment highlighted positivity for
CD68 and factor XIIIa. The specimen was negative for CD34, S100, and CD1a. A
diagnosis of class IIA histiocytoses; clinically in keeping with progressive nodular
histiocytosis (PNH) was made. Patient could not tolerate azathioprine. 6-mercaptopurine resulted in softening of large lesions and resolution of some smaller papules
but was stopped because of neutropenia. Methotrexate continued to improve
lesions but resulted in myelosuppresion. Lesions have resolved with hyperpigmentation and anetoderma-like changes. Class IIA histiocytoses are typically disorders of
dermal dendrocytes, leading to xanthogranulomatous reaction in the skin. Chu has
postulated that the various cell types form a continuum; from early vacuolated,
scalloped and xanthomatized cells to mature spindle-shaped cells, and that maturity
of these histiocytes is directly proportional to their resistance to adjunct therapy.
PNH is at the extreme end of this spectrum of lesions, with mature spindle cells, a
progressive evolution and resistance to therapy. PNH is characterized by the
predominance of cutaneous lesions, with mucous membranes, such as the larynx,
hard palate, and conjunctivae rarely affected. Lesions range from yellowish papules
to dermal nodules measuring from 5.0 mm to 5.0 cm, and not generally associated
with systemic involvement or hyperlipidemia. The condition is benign, but may be
disfiguring, with no treatment being shown to consistently induce remission.
Commercial support: None identified.
Livedoid vasculopathy (LV) is a chronic dermatosis characterized by recurrent
painful ulceration of the lower limbs, which heals to leave atrophie blanche.
Antiplatelet, anticoagulant, fibrinolytic therapies and antiinflammatory agents have
been reported to be helpful. However, no continuing benefit has been reported in
any of these modalities. Recently, pulsed intravenous immunoglobulin (IVIG)
therapy has been reported to be effective in some refractory cases. Outcomes in
7 patients treated with IVIG for treatment-resistant ulcerated LV were retrospectively analyzed. IVIg therapy was performed monthly at a dose of 2.0 g/kg body
weight divided over 3 to 5 consecutive days. Skin lesion before and after therapy was
assessed by a clinical score (sum of 3 items; erythema 0;3, ulceration 0;3, and pain
0;3). Six patients were treated by 3 cycles and 1 by 2 cycles. In all patients,
significant regression of skin lesions was observed after therapy resulting in a
decrease of the clinical score from 5.7 6 2.5 at the beginning to 1.0 6 1.4 after
therapy (P ¼.002). Two patients had no recurrences for 1.5 and 3 years each, but 5
patients relapsed; the median time to relapse was 9.8 months. Two of them were
retreated with IVIG and were improved consistently, and another 2 patients were
controlled with conventional oral medication. The complications such as nausea,
palpitation, and mild drug eruption were observed in some patients but well
tolerated. In all patients clinical evaluation revealed a marked improvement of
erythema, pain, and healing of areas of active ulceration. We propose that IVIg is a
rapid, effective, and safe therapeutic option in LV refractory to other treatment
modalities.
Commercial support: None identified.
P7973
P8612
Prospective, multicenter, pivotal trial evaluating the safety and effectiveness of microfocused ultrasound with visualization for improvement in
lines and wrinkles of the d
ecolletage
Mitchel P. Goldman, MD, Dermatology Cosmetic Laser Medical Associates of La
Jolla, Inc, San Diego, CA, United States; Michael H. Gold, MD, Tennessee Clinical
Research Center, Nashville, TN, United States; Steven H. Dayan, MD, Denova
Research, Chicago, IL, United States; Suzanne L. Kilmer, MD, Laser & Skin Surgery
Center of Northern California, Sacramento, CA, United States
Objective: To demonstrate aesthetic improvement in lines and wrinkles of the
decolletage with MFU-V.
Methods: 124 female subjects meeting inclusion and exclusion criteria were
enrolled and completed 1 treatment on the chest using 3 transducers: 4 e 4.5
mm (1.2 J), 7 - 3.0 mm (0.45 J), and 10-1.5 mm (0.20 J). Pain was assessed using a
validated scale (0-10) during the treatment. Standardized photographs were taken
before treatment, immediately after treatment, and at each follow-up visit (day 90
and 180). Efficacy will be determined by blinded validated Fabi/Bolton chest wrinkle
scale scoring at 180 days posttreatment compared to baseline Physician Global
Aesthetic Improvement Scale (PGAIS) scores and Patient Satisfaction Questionnaire
(PSQ) responses will be tabulated at days 90 and 180 posttreatment.
Results: 124 female subjects with a mean age of 56.7 years old (37 e 70), mean BMI
of 24.8 and Fitzpatrick skin types I-IV (I - 1%, II - 49%, III - 41%, and IV - 9%) were
enrolled. The mean pain score at each depth was 6.2 at 4.5 mm, 5.8 at 3.0 mm, and
4.8 at 1.5 mm. At time of submission, 116 subjects have completed visit 2 (day 90)
and 86 subjects have completed visit 3 (day 180). PGAIS scores show 75.0% have
improved at 90 days and 67.4% at 180 days. 84% of subjects noted an improvement
and 65.5% were satisfied at the 90-day visit. Visit 3 (day 180) results show a similar
trend with 80% of subjects noting improvement and 59.3% satisfied. Device-related
adverse events (AEs) reported have been mild tenderness and/or erythema, seen in
47% and 27% of subjects respectively. At this time, the only nonresolving AE has
been mild tenderness in 1 subject.
Recalcitrant dissecting cellulitis effectively treated with radiotherapy
Mansi Rajpopat, MBBS, Homerton University Hospital NHS Foundation Trust,
London, United Kingdom; Lindsey Yeo, MBBS, Aberdeen Royal Infirmary,
Aberdeen, United Kingdom; Nemesha Desai, MBBS, St John’s Institute of
Dermatology, London, United Kingdom; Stephen Morris, MBBS, St John’s
Institute of Dermatology, London, United Kingdom
Introduction: Dissecting cellulitis of the scalp (DCS) is a chronic suppurative disease
of the scalp of unknown etiology, most commonly affecting black men, aged
between 20 to 40 years. The condition can be extremely painful, disfiguring, and can
substantially impair quality of life. DCS is characterised by perifollicular pustules,
painful nodules, abscesses and interconnecting sinus tracts leading to scarring
alopecia. Management remains challenging and treatments include topical and
systemic antibiotics, isotretinoin, oral zinc, intralesional steroids, incision and
drainage of abscesses, laser excision and surgical resection. Successful treatment of
DCS using modern external beam radiation techniques is reported in a single 4-case
series. We report a fifth case of recalcitrant DCS successfully treated with
radiotherapy.
Case report: A 32-year-old male presented with a 10-year history of rapidly
progressive DCS. Trials of topical fucidin, betadine, isotretinoin, neotigasone,
rotational short courses of oral antibiotics, prolonged courses of clindamycin,
rifampicin, and dapsone had minimal impact. He suffered intractable pain, chronic
purulent discharge, and recurrent secondary impetiginisation. The significant
psychosocial impact lead to social isolation and low mood. A radiation test patch
was performed on the occipital scalp. Within 4 weeks, there was resolution of pain
and regression of nodules and abscesses within the treated field. He went on to
receive whole scalp radiotherapy comprising 8 Gy of 4 fractions for 2 weeks. He
remains in remission 30 months since initial radiation with significant improvement
in quality of life. There is hair loss over the field of treatment and a keloid scar over
the occipital area.
Conclusion: According to interim results, improvement in overall chest wrinkle
improvement has been demonstrated after 1 MFU-V treatment at 90 and 180 days
posttreatment. The primary limitation is that presently only preliminary data are
available, and the masked, validated assessment of chest wrinkle severity score
improvement will be conducted at day 180. This study is scheduled to be completed
by October 2013.
Discussion: DCS is part of the ‘‘follicular occlusion triad,’’ along with hidradenitis
suppurativa and acne conglobata. Modern external beam radiotherapy has been
used to manage an array of benign dermatoses, including keloid scars, inflammatory
skin disease, and disorders of follicular occlusion and its implementation has
resulted in minimal acute complications. Scarring alopecia is a long-term complication; however, it may in part reflect the disease process itself. There is a potential
risk of carcinogenesis; however, longer follow-up is required. We report clinically
effective treatment of recalcitrant DCS using radiotherapy and recommend
consideration of this modality in severe cases.
A research grant for this study was provided by Ulthera, Inc.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB53
P7676
P8547
Scalp care efficacy of a leave-on treatment based on niacinamide, caffeine,
and panthenol
James Schwartz, PhD, Procter & Gamble, Cincinnati, OH, United States; Christina
Gemmer, Procter & Gamble, Cincinnati, OH, United States; Holly Krigbaum,
Procter & Gamble, Cincinnati, OH, United States; James Henry, PhD, Procter &
Gamble, Cincinnati, OH, United States; Kerry Polmonari, Procter & Gamble,
Cincinnati, OH, United States
Background: Dry scalp is a common condition which can lead to a flaky appearance,
a tight feeling and excessive itchiness. There is a need for products to treat this
condition and prevent rapid reoccurrence.
Aim: We present data from a clinical study evaluating the improvement in scalp
condition as the result of daily use of a hydro-alcoholic-based leave-on scalp
treatment containing the triple combination of niacinamide, panthenol, and
caffeine.
Methods: A dry scalp clinical study was conducted among 36 males in which a leaveon scalp tonic was self-applied applied daily to one half of the scalp (randomized).
The population was prescreened to have a required level of visual dryness (expert
grade). Expert visual dryness, instrumental transepidermal water loss, and skin
surface biomarkers associated with epidermal maturation and barrier effectiveness
were assessed each week during the 3-week treatment period.
Skin toxicity following radioactive Strontium-89 (89Sr) administration:
A previously unreported adverse effect
Sairan Whitaker, MBChB, Royal Victoria Infirmary, Newcastle Upon Tyne, United
Kingdom; James Langtry, MBBS, Royal Victoria Infirmary, Newcastle Upon Tyne,
United Kingdom
Results: The use of the leave-on scalp tonic containing skin conditioning agents
niacinamide, panthenol, and caffeine demonstrated significant improvement, in
some cases as early as the first week, in reduced appearance of dryness,
improvement of barrier function, and normalization of biomarkers indicative of
epidermal maturation and stratum corneum barrier integrity.
Conclusion: A clinical study conducted amongst dry scalp males demonstrated the
benefits of a leave-on treatment containing niacinamide, caffeine, and panthenol for
improving dry scalp appearance, barrier function, and scalp health.
Sponsored 100% by Procter & Gamble.
Background: Strontium-89 (89Sr) has been used since 1989 as internal radiation for
pain relief and quality of life improvement in patients with osseous metastases. We
present, for the first time in the literature, a striking petechial rash as an adverse
effect of 89Sr therapy.
Case report: A 73-year-old presented with a 4-day history of a striking petechial rash
confined to the suprapubic and penile region developing 24 hours after the
administration of 161 MBq intravenous strontium-89 for bone metastases secondary
to hormone escaped metastatic prostatic adenocarcinoma. All investigations were
normal aside from a PSA of 326 and extensive and widespread sclerotic bone
metastasis. There was a sharply demarcated petechial rash to the supra pubic area
and penis, clearly outlining the bladder and directly overlying the penile urethra.
Patients are ‘‘radioactive’’ for 2 weeks after administration of strontium and invasive
procedures such as biopsy were not advised. The patient succumbed to chest sepsis
4 days later.
Discussion: Strontium-89 (89Sr) was approved in the late 80s as an unsealed
radioisotope for internal radiation therapy as an intravenous infusion and has been
used worldwide to provide pain relief in patients with osseous metastases. 89SR is
preferentially taken up by areas of metastatic bony disease, has a half life of 50.52
days, and often controls the notoriously difficult symptoms associated with bone
metastasis where analgesics and external beam radiation have failed. The short half
life and beta emission result in a lower risk of radiation compared to other Sr
isotopes. The major side effect after 89Sr administration reported in the literature is
myelosuppresion (leukocytes and platelet reduction by 20-30%) recovering 16
weeks after administration. Until now a skin rash is an unreported side effect.
Because of careful dose calculations and safeguards, toxic doses are very rare.
Approximately 90% of the 89Sr distributed in the soft tissues is discharged renally,
with a small amount excreted through the intestinal tract. Urinary excretion is
greatest in the first 2 days after injection, with the radioactivity remaining in the
blood circulation decreasing to 5% of the total dose 48 hours after injection. We
believe this correlates with the clinical picture and distribution of the rash in our
patient. This unreported side effect of strontium administration suggests that
catheterization should be advised in patients at risk of bladder outflow obstruction.
Commercial support: None identified.
P8273
Conclusions: Both the shampoo and the foam are effective at reducing the TDSS in
African American females. The F group had lower TDSS scores at week 4 despite
lower compliance. The F group were also more likely to be very satisfied with their
results. Lower TDSS scores in F group could be a result of better penetration because
of its alcohol base and longer contact time.
Sneddon syndrome: A case report
Ana Helena Kalies, Hospital E Maternidade Celso Pierro - PUC Campinas,
Campinas, Brazil; Adilson Costa, Hospital E Maternidade Celso Pierro - PUC
Campinas, Campinas, Brazil; Elisangela Pegas Pereira, Hospital E Maternidade
Celso Pierro - PUC Campinas, Campinas, Brazil; Maria Carolina Fidelis, Hospital E
Maternidade Celso Pierro - PUC Campinas, Campinas, Brazil; Raquel Favaro,
Hospital E Maternidade Celso Pierro - PUC Campinas, Campinas, Brazil;
Stephanie Selma Barros Langen, Hospital E Maternidade Celso Pierro - PUC
Campinas, Campinas, Brazil
Sneddon syndrome is a rare condition of unknown etiology which it is more
common amongst young women. It is characterized by the association between
livedo reticularis and ischemic cerebrovascular events. It is a systemic vasculopathy
which consists in a noninflammatory occlusive arteriopathy of the small and
medium arteries of skin and brain. This study is a case report of Sneddon syndrome.
It was a female patient, 42-year-old, with a 23-year history of persistent and
asymptomatic erythematous violaceous macules with a reticular pattern localized in
the trunk and members. Her medical history included a cerebrovascular event in the
past 2 years, convulsion crisis for 5 years, systemic hypertension for 10 years, and
repeated abortions. Laboratory examinations showed only low levels of platelets
(114,000/mm3); other tests were negative or normal. Histopathologic study of a pale
skin area at the center of the livedo showed absence of vasculitis or arterial
thrombosis. The brain MRI revealed microangiopathy of both hemispheres, brain
volume reduction, gliosis, and encephalomalacia in left middle cerebral artery
territory caused by a previous ischemic event. According to these last findings, it
was chosen to introduce acetylsalicylic acid 200 mg/day. The livedo racemosa in
Sneddon syndrome is the result of reduced blood flow because of occlusion of the
lumen of skin’s small arteries, clinically represented by reticular erythematous
violaceous macules. It has been associated with a variety of disorders, including
collagen diseases, vasculitis and hematologic and neurologic disorders. Literature
describes other manifestations, such as systemic arterial hypertension and pregnancy morbidity. Although there is no specific biologic marker for Sneddon
syndrome, laboratory examinations, histopathologic study of the skin, and brain
computerized tomography or MRI are recommended. The laboratory research is
needed to distinguish Sneddon syndrome and other conditions, such as antiphospholipid syndrome, coagulation disorders, systemic lupus erythematosus, and
infections. Treatment is complicated by the intermittent nature of the disease.
Sneddon syndrome is a rare but potentially severe condition that must be considered
in cases of livedo racemosa associated with cerebrovascular events. A more careful
description and follow-up of these cases is essencial to clarify some pathologic and
therapeutic aspects of this disorder.
GlaxoSmithKline provided the study medication.
Commercial support: None identified.
P8336
Seborrheic dermatitis of the scalp in populations practicing less frequent
hair washing: Ketoconazole 2% foam versus ketoconazole 2% shampoo.
Three-year data
Jeaneen Chappell, MD, Saint Louis University Department of Dermatology, Saint
Louis, MO, United States; Adam Mattox, DO, MS, Saint Louis University
Department of Dermatology, SainT Louis, MO, United States; Cassandra
Simonetta, MD, Saint Louis University School of Medicine, Saint Louis, MO,
United States; Eric Armbrecht, PhD, Saint Louis University Center for Outcomes
Research, Saint Louis, MO, United States; Mary Guo, MD, MS, Saint Louis
University Department of Dermatology, Saint Louis, Missouri, United States
Background: Hair wash frequency among ethnic groups was previously studied.
79.4% of African American female respondents reported less than once weekly hair
washing. To ensure adequate dosage and patient compliance, prescribed medications for scalp conditions should be formulated in vehicles that correlate with
patients’ hair care practices. We propose that a vehicle that does not require hair
washing would be more efficacious in this population.
Objectives: To determine if ketoconazole 2% foam (F) is more effective than
ketoconazole 2% shampoo (S) for the treatment of seborrheic dermatitis in the
African American female population. To determine if patients under treated with S
could achieve additional improvement with F. Patient compliance and satisfaction
were also evaluated.
Methods: African American women with mild to severe seborrheic dermatitis of the
scalp were enrolled into a prospective, investigator initiated, parallel-group, open
label, cross over trial. Disease severity was measured using the Total Dandruff
Severity Score (TDSS). Subjects were randomly assigned to receive either the S or F
for 4 weeks. Subjects who did not achieve a 60% improvement in TDSS crossed over
(CO) into the F group.
Results: 26 cases were analyzed (S ¼ 13, F ¼ 10, CO ¼ 3). Percent improvement by
week 4 was 62% vs 79%, S vs F (P ¼.46). Compliance was higher in the S group vs F
group, 73% vs 30%. The F group was more likely to report being very satisfied vs the
S group, 77% vs 46% (P ¼.33). The CO group achieved lower a TDSS using F vs S.
AB54
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8618
P8005
Solitary ulcerative lichen planus on the lower leg, a diagnostic challenge
Yasaman Mansouri, MD, Heart of England NHS Foundation Trust, Solihull, United
Kingdom; Manjit R. Kaur, MBBS, Heart of England NHS Foundation Trust,
Solihull, United Kingdom; Manju Paul, MBBS, Heart of England NHS Foundation
Trust, Solihull, United Kingdom; Ronald Muc, MBBCh, Heart of England NHS
Foundation Trust, Solihull, United Kingdom
Successful treatment of acquired idiopathic generalized anhidrosis using
intravenous immunoglobulin and oral minipulse steroid
Siew-Kiang Tan, MBBS, National Skin Centre, Singapore, Singapore; Hong-Liang
Tey, MBBS, National Skin Centre, Singapore, Singapore; Wei-Sheng Chong,
National Skin Centre, Singapore, Singapore
Lichen planus (LP) is a chronic, inflammatory, autoimmune disease that can affect all
body areas. Mucous membrane involvement is common (30-70%). While the exact
etiology is unknown, an immune-mediated pathogenesis is supported. A 77-year-old
woman presented with a 3-month history of a painless, nonhealing ulcer on the left
anterior shin following trauma. She was on long-term diclofenac and omeprazole for
osteoarthritis. Cutaneous examination revealed a superficial ulcer measuring 35 3
25 mm on the left anterior shin, which doubled in size within 2 weeks. Except for
Wickham striae on the buccal mucosa, the rest of the cutaneous examination
including genital mucosa, scalp, and nails was normal. An incisional biopsy showed
a broad area of ulceration flanked by hyperplastic and acanthotic epidermis;
prominent spongiosis with a florid interface reaction as indicated by numerous
necrotic keratinocytes and basal cell vacuolisation. A band-like infiltrate of mixed
inflammatory cells in the dermis was associated with significant numbers of
neutrophils, conspicuous vascular proliferation, and hemosiderin pigment deposits
focally. This was in keeping with ulcerative LP or lichenoid drug eruption (LDE).
Subsequently her medications were stopped and she was treated with clobetasol
propionate 0.05% under mepilex border lite dressings and doxycycline 100 mg daily,
which led to marked improvement within 5 weeks. As she had been on diclofenac
and omeprazole for many years, had mucosal involvement, and because of the
solitary nature of the ulcer, we favored a diagnosis of ulcerative LP rather than LDE.
While LP is common, the solitary ulcerative variant is extremely rare and is often
recalcitrant to treatment. Ulcerative LP has been described on the soles of the feet
and orogenital mucosa and rarely at other sites, such as groin, upper back, and lower
limb. Ulcerative LP on the leg can mimic a venous ulcer or malignancy; a biopsy is
therefore warranted for diagnostic confirmation and management. Patients with
chronic ulcerative lesions need to be followed up, because there is a risk of
squamous cell carcinoma arising within the lesions. Initial treatments include
topical steroids, topical tracrolimus, and intralesional steroids. Phototherapy and
systemic treatments are reserved for resistant cases. Our case highlights the
importance of keeping ulcerative LP as a differential diagnosis in patients presenting
with leg ulcers.
Commercial support: None identified.
Acquired idiopathic generalized anhidrosis (AIGA) is a rare disorder manifesting as
diffuse loss of sweating without abnormalities in other aspects of the autonomic
nervous system. The pathogenesis is unclear. Methylprednisolone pulse therapy and
high-dose oral steroids have been reported to be effective therapies, but the high
doses given for a prolonged period invariably induce serious side effects. Other
immunosuppressants, consisting of cyclosporin and azathioprine, were tried but
outcomes were inconsistent. We report 2 patients with AIGA who were successfully
treated: 1 with intravenous immunoglobulin (total dose 2.5g/kg) and the other with
oral minipulse steroid (20 mg 2 days a week for a month and escalated to 30 mg 2
days a week for 5 months). In addition to subjective improvement, both patients
demonstrated increased body surface area of sweating during the sweat-iodine tests.
Results were sustained for 6 months respectively. Both patients did not experience
any side effect. This is the first report of treatment of AIGA with such therapies,
which have a superior side effect profile compared to conventional high dose
systemic steroids.
Commercial support: None identified.
P8529
P8374
Stigmatization and coping among rosacea
Bruno Halioua, PhD, Institu Alfred Fournier, Paris, France; Julien Bourcier,
PharmD, Galderma International, La Defense, France; Marie-Eugenie Alvarez,
Galderma International Market Insights, La Defense, France
Background: Many patients with rosacea suffer from stigmatization regardless of the
severity or type of skin lesions.
Objectives: To assess the prevalence and the characteristics of rosacea patients who
report feelings of stigmatization (RFS) and their coping strategies.
Methods: A study was conducted in the UK, France, Germany, and the US, with a
representative sample of patients older than 18 years suffering from rosacea.
Participants completed a clinical questionnaire which allow gathering sociodemographic profiles, self-reported and disease histories. Patients were considered as
report feelings of stigmatization (RFS) when they reported that they felt dirty/ugly
because of their skin condition and/or that they were subject of stares, misconceptions, rude comments or jokes because of their skin condition. Student t test
and test of the chi-squared of Pearson were performed to compare RPS and non RPS.
Results: A total of 807 patients in France, Germany, UK, and US met the inclusion
criteria and completed the survey. Among them, 275 reported feelings of
stigmatization. RFS represented 34,1 % of the sample. Men reported feelings of
stigmatization more frequently than women (49% vs. 37.2%; P ¼ .0029) and were
younger (mean age, 36.9 years old vs 46.2; P ¼ .014). A significant part of these
patients (54.2% vs 2%; P ¼ 3.32E-31) adopted coping strategy which consisted in
avoiding public contact or cancelling social engagements because of their rosacea.
Marital status, level of education, current employment status and occupation were
not significantly different between RFS and non RFS. Symptoms associated with
rosacea such as flushing (P ¼ .044), telangiectasias (P ¼ 9.51E-07), papules and
pustules (P ¼ 1.1E-08), and rhinophyma (P ¼ 1.33E-05) were all significantly more
frequent in RFS. Ocular involvement was not a significant predictors of stigmatization feelings (P ¼.579) and red face to a low extent (P ¼.145). Among 223 RFS, the
main reasons for consulting were significantly the following: esthetic aspect of the
lesions (P ¼ .65), emotional impact (P ¼ .007) and sensations (burning, itching,
sensitivity, dryness, and irritation; P ¼.007). There are significant consequences on
everyday life, and on social and professional life, among RFS.
Conclusion: This is the first study of stigma in rosacea which emphasizes the
importance of considering the stigmatization experience and coping in rosacea
patients in both future studies and patient treatment.
Sponsored by Galderma International.
Sweating, suicidality, and autonomic nervous system hyperarousal in
posttraumatic stress disorder: Clinical features and treatment implications
Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicine
and Dentistry, University of Western Ontario, London, Ontario, Canada; Aditya K.
Gupta, MD, PhD, Division of Dermatology, Department of Medicine, University
of Toronto, London, Ontario, Canada
Background: Symptoms of autonomic nervous system (ANS) hyperarousal is a core
feature of PTSD. Hyperhidrosis is a symptom of ANS hyperarousal. PTSD has been
consistently associated with higher rates of suicidal ideation and suicide attempts,
which have been attributed in part to the ANS hyperarousal. There is only 1 case
report describing a possible association between night sweats and PTSD.
Objective: Examine the frequency of hyperhidrosis and related clinical features in
PTSD patients.
Method: 20 patients (all female, mean 6 SD age: 45.6 6 6.2 years, 18 white) with
chronic PTSD (DSMIV-TR) and 20 age- and sex-matched controls with mood
disorders (DSMIV-TR) (also associated with greater suicidality), underwent a
detailed evaluation of somatic complaints related to the ANS, including hyperhidrosis. Suicidality was measured with the Beck Scale for Suicidal Ideation (BSS).
Results: 12 (60%) PTSD patients [versus 1 (5%) of controls] reported a history of
hyperhidrosis in association with exacerbations of the PTSD. The hyperhidrosis had
first manifested with the onset of PTSD symptoms when the patients were not
menopausal. All other investigations for hyperhidrosis (eg, tuberculosis, malignancy,
etc) were negative. The hyperhidrosis manifested as profuse night sweats; during
the daytime, patients described periods, sometimes lasting for several days, when
they would perspire profusely and much more easily (eg, after minimal exertion). 10
out of 12 PTSD patients with hyperhidrosis also endorsed heightened suicidality, and
4 out of 12 had attempted suicide necessitating hospitalization. There was no
association of increased suicidality with hyperhidrosis in the control group. All
patients were treated with mood stabilizers (eg, lithium carbonate up to 900 mgs
qhs, lamotrigine up to 150 mgs qhs) for managent of the ANS hyperarousal. There
was a significant improvement in both hyperhidrosis and suicidality (all BSS scores
\3) within 3 to 4 weeks of initiation of the mood stabilizer.
Discussion: Hyperhidrosis, a dermatologic manifestation of ANS hyperarousal in
PTSD, was associated with acute suicidality. Management of the ANS hyperarousal
with mood stabilizers was associated with a significant improvement in both
hyperhidrosis and suicidality. Our findings suggest that the presence of unexplained
hyperhidrosis in the PTSD patient should alert the clinician re. underlying ANS
hyperarousal and greater suicide risk.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB55
P8306
P8522
The patient journey: A novel approach to conceptualizing rosacea
patients’ experiences
Sandy Kuo, MS, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Karen Huang, MS, Wake Forest School of Medicine, Winston-Salem, NC,
United States; Scott Davis, MEd, Wake Forest School of Medicine, Winston-Salem,
NC, United States; Steven Feldman, MD, PhD, Wake Forest School of Medicine,
Winston-Salem, NC, United States
Background: What motivates rosacea patients to seek and adhere to treatment is not
well characterized. A patient journey is a map of the steps a patient takes as he or she
progresses through different segments of the illness from diagnosis to successful
management, including all the influences that can push him or her toward or away
from certain decisions.
Purpose: To examine each step of the patient journey to better understand key
patient care boundaries faced by rosacea patients.
Methods: PubMed and the National Rosacea Society were searched to identify
articles and materials that quantitatively or qualitatively describe rosacea patient
experiences. Current literature pertaining to the patient journey was summarized.
Results: Despite having symptoms, most patients wait up to 5 years before seeking
treatment. Long-term treatment is often required for maintenance, which can last
longer than 6 months. 28% of rosacea patients took time off from their treatment
regimen; actual nonadherence is likely higher.
Limitations: Limited literature exists on the rosacea patient experience.
Treatment of posterior cheek enlargement in HIV+ patients with
botulinum toxin A
Christina Scali, PhD, MD, Department of Dermatology and Skin Science,
University of British Columbia, Vancouver, British Columbia, Canada; Alastair
Carruthers, Department of Dermatology and Skin Science, University of British
Columbia, Vancouver, British Columbia, Canada; Shannon Humphrey,
Department of Dermatology and Skin Science, University of British Columbia,
Vancouver, British Columbia, Canada
Posterior cheek enlargement is very common in a subset of individuals infected with
HIV. This can lead to significant cosmetic disfigurement and social stigmatization.
Both the parotid gland and masseter muscle overlie the mandibular ramus, thus
contributing to the lower facial contour. Although parotid enlargement is a common
finding in HIV-associated salivary gland disease, masseter muscle enlargement may
also contribute. The aesthetic appearance may also be caused by apparent muscle
enlargement attributable to facial lipoatrophy. Although parotid hypertrophy is a
recognized and common complication of HIV, treatment options are limited and
ineffective. These include highly active antiretroviral therapy (HAART), steroids,
radiation and surgical resection of tissue, which can result in significant morbidity.
Botulinum toxin is a highly efficacious, minimally invasive option for reducing the
width and improving the shape of the lower face. It has been used in HIVe
individuals with square faces to reduce the size of the masseter muscle. We are
undertaking a pilot study to characterize posterior cheek enlargement in HIV+
patients and explore treatment with botulinum toxin A. We have 4 participants with
posterior cheek enlargement that have had baseline photographs and a head CT scan
in order to determine whether the masseter muscles and/or parotid glands are
enlarged. Botulinum toxin A was injected into the region of enlargement.
Participants were evaluated clinically at 4, 8, and 12 weeks after injection, as well
as with photographs and a questionnaire assessing patient satisfaction and side
effects. A head CT scan was performed 12 weeks after injection to calculate the
precise reduction in volume that occurred from botulinum toxin A. Long-term
efficacy will then be evaluated at 6 and 12 months postinjection. Before the study
commenced, an HIV+ patient with posterior cheek enlargement was successfully
treated with botulinum toxin A with excellent results. There was a 19.0% and 19.4%
mean reduction in the volume of the parotid glands and masseter muscles,
respectively. The effect was longlasting even at 6 months postinjection, and well
tolerated, with no side effects reported. This research may eventually lead to a
minimally invasive treatment for posterior cheek enlargement in HIV+ patients, with
advantages of a result that is long-lasting with good tolerability and minimal risk to
the patient.
Conclusions: The patient journey is a useful tool to gain important insights of the
patient experience. Better understanding of the patient perspective can lead to
better patient adherence to treatment, and thus improved quality of life and
satisfaction.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
Commercial support: None identified.
P8230
Trichotillomania: Demographic and clinical characteristics in an
epidemiologically representative sample from the United States
Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicine
and Dentistry, University of Western Ontario, London, Ontario, Canada; Aditya K.
Gupta, MD, PhD, Division of Dermatology, Department of Medicine, University
of Toronto, London, Ontario, Canada; Katie Knapp, MS, Department of
Psychiatry, Schulich School of Medicine and Dentistry, University of Western
Ontario, London, Ontario, Canada
P7921
The role of human papillomavirus in the developement of cutaneous
squamous cell carcinoma: A metaanaylsis
Bishr Aldabagh, MD, University of California-San Francisco, San Francisco, CA,
United States; Jennifer Wang, New York University School of Medicine, New
York, NY, United States; Justin Yu, St. Louis University School of Medicine, St.
Louis, MO, United States; Sarah Arron, MD, PhD, University of California-San
Francisco, San Francisco, CA, United States
Background: The role of HPV in cutaneous squamous cell carcinoma (cuSCC) has
not been well defined in the general population, although the clinical behavior and
epidemiology of SCC suggests a viral etiology. Past studies have shown conflicting
results, and studies showing HPV infection in SCC have reported variable ranges of
detection.
Objectives: We sought to determine if there is a significant association between HPV
and cuSCC and to determine whether cuSCC from immunosuppressed patients are
more likely to carry HPV than cuSCC from immunocompetent patients.
Methods: We performed a systematic review of the literature and abstracted data
from articles in which skin samples were collected by biopsy, HPV detection was
done by PCR, and a minimum of 10 cases and 10 controls were used. Pooled effect
size and 95% confidence intervals were calculated using random effects
metaanalysis.
Results: In the pooled data, cuSCC were more likely to carry HPV than normal skin
(pooled ES 2.91; 95% CI, 1.52-5.58; P ¼ .001) in both immunosuppressed and
immunocompetent patients. An increase in HPV prevalence was found in tumors
from immunosuppressed patients compared to immunocompetent patients (pooled
ES 2.68; 95% CI, 1.94-3.72; P \.0001).
Conclusions: These results contribute to the body of evidence that HPV is associated
with cuSCC. Higher HPV burden in tumors from immunosuppressed patients
compared to immunocompetent patients may have therapeutic implications. While
further research is needed and the significance of HPV positive tumors is unknown,
it may lead to more targeted treatment modalities, reduction of disease burden, and
better patient outcomes.
Commercial support: None identified.
AB56
Background: Trichotillomania (TTM) is psychodermatologic condition which is
typically first seen in a dermatology setting and has been associated with a wide
range of psychiatric factors. Epidemiologic studies of TTM have tended to focus on
specific populations, including university students and psychiatric patients; there
are 2 studies from community samples; however, both found \6 cases of TTM that
met standard diagnostic criteria. There are no studies of TTM from large scale
nationally representative samples .
Objective: We examined demographic and clinical characteristics of TTM in the
National Ambulatory Medical Care Survey (NAMCS) and the National Hospital
Ambulatory Medical Care Survey (NHAMCS), which are both nationally representative samples of patient visits in the US.
Methods: Retrospective cross-sectional analysis of NAMCS and NHAMCS databases
from 1995 to 2010 consisting of 1,442,259 patient visits (unweighted count) for all
possible diagnoses coded using ICD9-CM. TTM was coded using the ICD9-CM code
312.39.
Results: There were an estimated (6SE) 695, 588 6 136, 456 patient visits with TTM
(unweighted count ¼ 89), representing 0.004% of the entire sample and 0.056% of
patient visits with a psychiatric diagnosis. TTM patients were more likely to be
female (OR 2.88; 95% CI, 1.33-6.20); however, there was no sex difference in the
\12 years age group. TTM was more common in the ¼ 25 years versus [25 years
age group (OR 6.79; 95% CI, 2.79-16.50). There was no difference in frequency of
TTM between ‘‘white’’ versus ‘‘black/African American’’ patients. 98.9% 6 0.1% of
TTM visits had a comorbid condition; only 29% 6 9.8% had a comorbid diagnosis
that was not psychiatric. TTM was most likely to be comorbid with depressive
disorders (OR 18.51; 95% CI, 8.34-41.10). Other psychiatric disorders provisionally
associated with TTM (unweighted count \30) were: all anxiety disorders (OR 8.93;
95% CI, 1.99-40.15), obsessive-compulsive disorder (OR 186.17; 95% CI, 57.13606.66), and ADHD (25.44; 95% CI, 9.66-67.00).
Conclusion: The results from a nationally representative sample support findings
from smaller scale studies of TTM and the major diagnostic clinical features of TTM
described in the DSM-5 (American Psyhiatric Association, 2013). Our results also
suggest that the dermatologist should have a high index of suspicion for other
psychiatric comorbidities when managing the TTM patient.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8553
P7864
Two cases of burn-related skin grafts demonstrating locus minoris
resistentiae
Priyanka Vedak, Massachusetts General Hospital, Boston, MA, United States;
Daniela Kroshinsky, MD, MPH, Massachusetts General Hospital, Boston, MA,
United States; Philip I. Song, MD, Massachusetts General Hospital, Boston, MA,
United States; Sherrie J. Divito, MD, PhD, Massachusetts General Hospital,
Boston, MA, United States
Introduction: Locus minoris resistentiae (LMR) is the phenomenon where lesions
preferentially present at sites of reduced skin integrity over those areas in which the
barrier function is intact. Most of the literature describes this phenomenon for areas
previously afflicted by herpesvirus or other infection, with the secondary disease
process most commonly being a granuloma annulare-type reaction. Those few cases
eczema. The following cases are unique in that they were id reactions localizing to
involving skin grafts almost exclusively describe the development of a secondary
prior burn or skin graft donor sites.
Case reports: Case 1: A 50-year-old man with a history of campfire burns over his left
trunk and left upper extremity status postesplit-thickness skin grafts presented with
a new pruritic well-demarcated eruption over his feet after wearing moist boots for a
prolonged period of time. Amoxicillin was initiated by his primary team given the
concern for cellulitis. Two days later, the patient noted a new pruritic and burning
eruption involving his trunk and bilateral upper extremities exclusively in areas of
the graft and prior burn sites. Dermatology consultation revealed thin annular
erythematous plaques with scale over the dorsal foot and toes with interdigital scale,
and numerous edematous erythematous papules concentrated only in areas of
healed graft sites. A diagnosis of tinea pedis-induced id reaction demonstrating LMR
was made. Case 2: An 8-year-old girl had a history of multiple surgeries for skin
grafting following severe burn injuries sustained from igniting hair spray with a
lighter. She presented with a pruritic rash on postoperative day 1 statusepostrelease
engraftment of her left neck and axillae burn sites. Physical examination revealed
diffusely scattered erythematous blanching papules along with edematous firm
papules exclusively on the burn injury sites on her upper back, neck, and shoulders,
and her graft donor sites on her legs, with a square-shaped plaque on the upper back
corresponding to occlusion under a dressing. Dermatology consultation yielded a
diagnosis of id reaction induced by contact dermatitis secondary to intraoperative
chlorhexidine application. She improved with topical steroids and antihistamines.
Conclusion: These 2 cases not only demonstrate that burn and graft sites can behave
as LMR loci, but also represent the only cases to our knowledge of id reactions
demonstrating LMR.
What’s the matter with injections? Nicolau syndrome
Claudio Guarneri, MD, Department of Clinical and Experimental Medicine,
University of Messina, Messina, Italy; Achille Patrizio Caputi, MD, Department of
Clinical and Experimental Medicine, University of Messina, Messina, Italy;
Giovanni Polimeni, PharmD, PhD, IRCCS Neurolesi ‘‘Bonino-Pulejo’’ University of Messina, Messina, Italy; Serafinella Patrizia Cannav
o, MD,
Department of Clinical and Experimental Medicine, University of Messina,
Messina, Italy
Embolia cutis medicamentosa (Nicolau syndrome) is a rare, still unexplained
complication of injection of several drugs, clinically characterized by cutaneous,
subcutaneous and even muscular aseptic necrosis in a livedoid pattern. Firstly
described by Freudenthal and Nicolau in 1925, it typically presents with pallor,
owing to a local reflex vasospasm, and pain, rapidly followed by erythema,
haemorrhagic patch, blistering, and variable degree of necrosis. On pathogenesis,
experimental data seem to disprove the possible allergic/immunologic pathomechanism, as well as the role of chemicalephysical features of the drug, the solution
pH or the injection technique. Most reasonable hypothesis remains that of an
unintentional paravasal administration, leading to vessel wall damage, acute arterial
thrombosis, and subsequent necrosis. Several drugs have been associated with
Nicolau syndrome, injected intramuscularly, intraarticularly, and subcutaneously,
using different kinds of needles and medical devices (including electronic injection
devices). Through presentation of some clinical cases, the authors discuss ‘‘new,’’
practice-based, evidence on this unusual and avoidable complication.
Commercial support: None identified.
Commercial support: None identified.
P7697
Unusual presentation of erythema multiforme in a patient with scleroderma/mixed connective tissue disease
Joyce Wang, Boston University School of Medicine, Boston, MA, United States;
Emmy Graber, MD, Boston University, Boston, MA, United States; Lynne
Goldberg, MD, Boston University, Boston, MA, United States; Yoon-Soo Cindy
Bae-Harboe, MD, Laser and Skin Surgery Center of New York, New York, NY,
United States
Erythema multiforme (EM) is a condition of unclear etiology clinically characterized
by targetoid lesions and typically associated with HSV or other infection in young
adults. Rowell syndrome is a rare syndrome that commonly presents as unexplained
recurrent EM in middle-aged patients with lupus erythematosus (LE). We report a
possible variant of Rowell syndrome: a case of recurrent EM in a middle-aged patient
with scleroderma/mixed connective tissue disease (MCTD) and no signs of an
infectious etiology. A 44-year-old female with a history of scleroderma/MCTD was
admitted for 1 day of a diffusely burning and pruritic rash. Two months prior, the
patient presented at an outside hospital with similar lesions and a biopsy consistent
with EM. She was treated with 2 g of acyclovir daily and a prednisone taper with
complete resolution of the lesions. She denied a history of cold sores, genital herpes,
recent illness, new medications, recent travel, or contact with pets or children.
Physical examination revealed well-demarcated, round to irregularly shaped pink
blanching macules, patches and plaques without scale on the right forearm, right
axilla, bilateral elbows, bilateral inguinal areas, and in the gluteal cleft. Tender pink
to violet edematous plaques were found diffusely on the bilateral palms, and medial
and lateral feet extending to the soles and toes. Her serology was positive for ANA
(1:640) in a speckled pattern, rheumatoid factor (RF), and anti-Ro/SSA and antiLa/SSB antibodies. Biopsies from the right axilla and left foot were again consistent
with EM. The patient was discharged on prednisone 40 mg by mouth tapering every
5 days by 10 mg for 20 days. Fluocinonide cream 0.05% and Benadryl were given for
symptomatic relief. Her lesions cleared within 2 weeks, and at 1-year follow-up she
had not yet experienced any repeat episodes. To our knowledge, this is the first
report of EM in association with scleroderma or MCTD. Interestingly, our patient is
serologically identical to patients with Rowell syndrome, a rare entity characterized
by EM-like lesions in conjunction with LE, and seropositivity for RF and ANA in a
speckled pattern. Also similar to patients with Rowell syndrome, she was a middleaged woman with no identifiable triggers for her recurrent EM. While a coincidental
association cannot be ruled out, this case supports the possibility that patients
with collagen vascular disease and particular serologic findings may be predisposed
to EM.
P7822
Commercial support: None identified.
Commercial support: None identified.
Wolf’s isotopic response: Presenting as granulomatous folliculitis
Kirstin Altman, MD, University of Wisconsin, Department of Dermatology,
Madison, WI, United States; Daniel Bennett, MD, University of Wisconsin,
Department of Dermatology, Madison, WI, United States; Rita Lloyd, MD,
Univeristy of Wisconsin, Department of Dermatology, Madison, WI, United States
Various skin eruptions have been described in herpes zoster scars. We are reporting
a case of granulomatous folliculitis, developing at a site of previous herpes zoster in a
48-year-old woman. Cutaneous reactions presenting in skin that had been affected
by a herpes virus infection has been termed ‘‘Wolf’s isotopic response.’’ Isotopic
response represents a new disease process within the location of a previous disease.
Granulomatous changes have been reported, but granulomatous folliculitis is rare.
The pathogenesis of the isotopic response is unclear. The absence of viral DNA in
the majority of lesions suggest a different etiology than the persistence of herpes
virus. Treatment is often not necessary in the spontaneously resolving lesions, but
resolution might be hastened by application of topical steroids. The lesions in our
patient resolved with application of topical triamcinolone. Wolf’s isotopic response
is a rare entity and awareness can aid in the diagnosis and prevent recurrent
treatment with antivirals.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB57
P8712
P8574
Xanthoma-like skin lesions on scrotum involved in systemic AL
amyloidosis
Minh Van Hoang, MD, University of Medicine and Pharmacy of Ho Chi Minh City,
Ho Chi Minh, Vietnam; Phung Kim Thi Ngo, MD, PhD, University of Medicine and
Pharmacy of Ho Chi Minh City, Ho Chi Minh, Vietnam; Thang Hiep Duc Tran,
MD, Gia Dinh People Hospital, Ho Chi Minh, Vietnam; Thu Minh Vu Tran, MD,
Cardiology Tam Duc Hospital, Ho Chi Minh, Vietnam; Vinh Nguyen Pham, MD,
PhD, Cardiology Tam Duc Hospital, Ho Chi Minh, Vietnam
Systemic AL amyloidosis is a rare disease. It involves kidney, heart, peripheral nerves,
liver, and skin. Cutaneous manifestations are common in amyloidosis on anywhere
of the body but the scrotum. We report a case of systemic AL amyloidosis with heart
failure and xanthoma-like eruption on the srotum. A 13-year-old boy was admitted to
hospital for edema. Physical examination showed right heart failure and he was
diagnosed restrictive cardiomyopathy. A work-up for restrictive cardiomyopathy was
inititated . Abdominal fat and tongue biopsy confirmed the presence of multiple
amyloid deposites, positive for Congo red stain. So a clinical diagnosis of cardiac
amyloidosis was made. Two years later, he got xanthoma-like eruption on the left
quarter srotum. Histopathology showed the fibrovascular tissue including collagen
bundles and vessels with some bundles of smooth muscle. The smooth muscle and
collagen bundles are seperated by an amorphous material which is weak PAS+ and
congophilic, with green birefringence. Staining was somewhat resistent to permanganate digestion. In immunofluorescent staining, it was IgAe, IgGe, IgMe, fibrine,
lamdae and only a small amount of material was kappa+. Scrotal skin biopsy revealed
amyloid deposition in scrotal skin area, immunofluorescence indicated AL amyloidosis, probably of kappa origin. Recently, scrotum skin amyloidosis has never been
reported in the literature.
Cutaneous manifestation of Degos disease
Aparna Tamirisa, MD, Center for Clinical Studies, Webster, TX, United States;
Christopher Downing, MD, Center for Clinical Studies, Webster, TX, United
States; Farhan Khan, MD, MBA, Center for Clinical Studies, Houston, TX, United
States; Stephen Tyring, MD, PhD, Dermatologic Association of Texas, Webster,
TX, United States
Commercial support: None identified.
Introduction: Degos disease or malignant atrophic papulosis is a rare and potentially
fatal vasculopathy with fewer than 200 cases noted in the medical literature. With a
median survival of 2 to 3 years, systemic Degos disease becomes an important
clinical phenomenon to recognize.
Case report: A 38-year-old woman with a history of undifferentiated connective
tissue disease presented with a 4-week history of lesions of the finger and thumb.
She described these lesions as red papules which then progressed to form a scar
with a depressed white center. On examination, the lesions of the finger and thumb
had an erythematous rim with a porcelain white central atrophic scar. A punch
biopsy from the thumb revealed infarction and focal erosion of the epidermis with
abundant mucin in the papillary dermis. Some of the histologic features were
suggestive of Degos disease, and a repeat biopsy of a lesion in an earlier phase was
suggested to confirm the diagnosis. The patient presented with a new lesion of the
toe. A shave biopsy of the lesion showed a wedge-shaped infarct with abundant
mucin and chronic inflammation, findings confirming a diagnosis of Degos disease.
Discussion: Degos disease is an extremely rare vasculopathy affecting the medium
and small vessels, resulting in blockage and tissue infarction. It generally occurs in
the second to fourth decades of life. The initial manifestation of disease is cutaneous,
beginning as an erythematous papule which heals over 4 to 6 weeks to form scar
with a telengiectatic rim and a pathognomonic white porcelain atrophic center. The
systemic manifestations appear within weeks to years of the initial skin findings, and
the gastrointestinal tract is the most commonly affected organ system. It is important
to note that while there is a benign and exclusively cutaneous form of the disease
known as Degos acanthoma, systemic Degos disease is a potentially fatal multiorgan
variant. The pathogenesis of Degos disease is unclear. It is thought to be a disease of
the complement system, clotting factors, or endothelial cell dysfunction as opposed
to an immune-mediated vasculitis. The differential diagnosis of Degos disease
include lupus and antiphospholipid antibody syndrome. There is no proven
treatment and current options include antiplatelet and anticoagulant drugs.
Commercial support: None identified.
CONNECTIVE TISSUE DISEASES
P8589
ChurgeStrauss granuloma in a patient with rheumatoid arthritis.
Julio Jasso Olivares, MD, Instituto Nacional de Ciencias Medicas y Nutrici
on
‘‘Dr. Salvadar Zubiran,’’ Mexico City, Mexico; Dalia Rodriguez Acosta, MD,
Instituto Nacional de Ciencias Medicas y Nutrici
on ‘‘Dr. Salvadar Zubiran,’’
Mexico City, Mexico; Judith Dominguez-Cherit, MD, Instituto Nacional de
Ciencias Medicas y Nutrici
on ‘‘Dr. Salvadar Zubiran,’’ Mexico City, Mexico;
Linda Garcia Hidalgo, MD, Mexico DF, Mexico
Introduction: ChurgeStrauss granuloma (ChSG) or palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare condition described by Dykman in 1965. It
occurs primarily in patients with rheumatoid arthritis (RA). Currently it is
considered that is triggered by subacute or chronic leukocytoclastic vasculitis,
which is caused by deposits of immune complexes in blood vessels of patients with
connective tissue diseases (CTD) and leads to degeneration of collagen initiating an
immune response culminating in the formation of a palisading granuloma. Clinically,
patients have skin-color or erythematous nodules that can be itchy distributed in
elbows, wrists or fingers. Differential diagnoses are: rheumatoid nodules, granuloma
annulare (GA) and erythema elevatum diutinum.
P8452
Case report: A 56-year-old woman who had several symmetrical nodules arcdistributed localized to upper limb flexor area, some of them had hematic crusts
because of scratching, 6 months duration and was associated with untreated RA.
With a presumptive diagnosis of GA vs ChSG we performed a punch biopsy, which
reported PNGD. Our patient was treated with topical steroid (betamethasone) and
methotrexate for underlying disease achieving clinical remission.
Discussion: The histologic appearances of PNGD vary from necrobiotic granulomatous pattern with vasculitic reaction to a poorly defined granuloma with
disorganized histiocytes, leukocytoclasia, nuclear dust, and characteristically
absence of mucin. Treatment of the underlying disease achieves remission in up
to 68% of patients; however, there are reports of remission with topical or systemic
steroids with or without methotrexate, or dapsone. The DGNE is a differential
diagnosis that must be thought in patients with CTD and nodular lesions whose
diagnosis can only be achieved through careful histopathology analysis.
Dermatomyositis in the setting of myxoid chondrosarcoma
Lauren Strazzula, Massachusetts General Hospital, Boston, MA, United States;
Daniela Kroshinsky, Massachusetts General Hospital, Boston, MA, United States;
Eli Miloslavsky, Massachusetts General Hospital, Boston, MA, United States; Lyn
Duncan, Massachusetts General Hospital, Boston, MA, United States; Matthew
Baker, Massachusetts General Hospital, Boston, MA, United States; Rosalynn
Nazarian, Massachusetts General Hospital, Boston, MA, United States; William
Tsiaras, MD, PhD, Massachusetts General Hospital, Boston, MA, United States
A 51-year-old woman presented to the outpatient dermatology clinic with a 2-month
history of tender red papules on the hands, arthralgias, and steroid-responsive
muscle weakness. She also reported a 4-day history of headaches, double vision, and
right-sided facial weakness. Her laboratories were significant for an elevation in
creatinine kinase and aldolase. Anti-CADM 140 antibody was detected, however, all
other myositis specific autoantibodies were negative. A skin biopsy of the one of the
hand lesions revealed interface dermatitis with dermal mucinosis, consistent with
connective tissue disease such as lupus or dermatomyositis. Given her neurologic
symptoms, a magnetic resonance imaging (MRI) study was performed of the brain
revealing a 5.5-cm right cranial mass. Subsequent biopsy of this mass showed
findings consistent with a myxoid chondrosarcoma. Dermatomyositis is connective
tissue disorder often presenting with rash and proximal muscle weakness which can
be associated with malignancy in up to 25% of cases, usually gastrointestinal or
genitourinary. The incidence of malignancy-associated dermatomyositis increases
with patient age. To the authors’ knowledge, this is only the second reported case in
the English literature of dermatomyositis arising in the setting of a chondrosarcoma.
The patient was started on prednisone and then methylprednisone, which resulted
in resolution of her rash and muscle weakness. Myositis-specific autoantibody
positivity is rarely observed in malignancy-associated dermatomyositis. This case of
dermatomyositis arising from a rare tumor enforces the need for high clinical
suspicion and thorough screening when assessing and diagnosing a patient with
suspected malignancy-associated dermatomyositis.
Commercial support: None identified.
Commercial support: None identified.
AB58
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8433
P8494
Linear scleroderma in an adolescent female treated with methotrexate
and excimer laser
Anne Hanson, DO, Saint Joseph Mercy Hospital, Ypsilanti, MI, United States;
Brian Schapiro, MD, Saint Joseph Mercy Hospital, Ypsilanti, MI, United States;
David Fivenson, MD, Saint Joseph Mercy Hospital, Ypsilanti, MI, United States
Monozygotic twins concordant for disseminated discoid lupus
Virginia Martinez, MD, Centro Dermatologico Ladislao de la Pascua, Mexico City,
Mexico; Alberto Ramos, MD, Centro Dermatologico Ladislao de la Pascua,
Mexico City, Mexico; Cesar Maldonado, MD, Centro Dermatologico Ladislao de
la Pascua, Mexico City, Mexico; Eliana Gomez, MD, Centro Dermatologico
Ladislao de la Pascua, Mexico City, Mexico; Fermin Jurado, MD, Centro
Dermatologico Ladislao de la Pascua, Mexico City, Mexico
A 17-year-old white female presented with a 4-year history of slowly expanding
disfiguring lesion on her left flank. The lesion started as a violaceus plaque that
would become erythematous and painful with heat and exercise. The lesion
gradually became depressed and hard. She recalled no trauma or insect bite in that
area. On initial presentation, physical examination revealed a 20 3 4 cm slightly
hyperpigmented, depressed, indurated, linear plaque extending from her left flank
to left lower quadrant of the abdomen. Over the next 6 months, the plaque extended
from the anterior tip of the tenth rib to the symphysis pubis. An open wound
developed at the superior aspect after an attempt at partial excision of the most
painful portion of the lesion. Biopsy revealed findings consistent with morphea. A
later excisional biopsy of a persistent nonhealing focus of the plaque revealed
dermal thickening and sclerosis with superimposed dermal calcification and
perforation. Treatment included intralesional steroid injections and topical calcipotrene ointment. She was also treated with methotrexate 5 mg weekly and twice
weekly excimer laser for a total of 34 treatments and a maximum of 2200
mJ/treatment. The lesion decreased in size considerably with relief of symptomatic
discomfort by 2 months. Localized scleroderma (LS), or morphea, is an autoimmune
disease of the skin and underlying subcutaneous tissue primarily affecting the
pediatric population. Linear scleroderma is the most common type in children and
can also be the most severe, causing joint contractures on the extremities or strokes,
optic neuritis, or seizures when involving the head. The monochromatic excimer
light laser is a narrowband UVB laser emitting at 308 nm. The excimer has been
reported to effectively treat a multitude of dermatologic conditions including
localized scleroderma. The excimer laser is believed to deplete T cells, alter
apoptosis-mediating molecules, and decrease cytokine expression. Methotrexate is
immunosuppressive folate anaglog agent used to treat rheumatoid arthritis as well as
severe psoriasis. It is also useful for the acute and deep form of scleroderma. It has
been shown to decrease levels of IL-2, IL-6, tenascin, and mast cells. These 2 agents
together prove to be very effective therapy for linear morphea in conjunction with
traditional therapies.
Discoid lupus erythematosus is a chronic form of cutaneous lupus. It is classified as
localized when the head and neck are the only affected areas, and as disseminated
when it extends to the trunk and limbs. It may occur alone or in the context of
systemic lupus. Although systemic lupus erythematosus has often been reported in
identical twins, discoid lupus erythematosus has only occasionally been described.
We report the case of two 4-year-old Mexican monozygotic twin girls with
disseminated discoid lupus. The patients presented with an 18-month history of
asymptomatic lesions on lower eyelids, nose, cheeks, scalp, ears, chest, forearms,
and hands. Physical examination revealed multiple erythematosus scaly indurated
plaques. A skin biopsy specimen from nose revealed epidermal atrophy, follicular
plugs, thickened basement membrane, vacuolar degeneration of the basal layer, and
superficial, deep, periadnexal, and perivascular lymphocytic infiltrate. Serologic
evaluation revealed a positive SSA/Ro antibody in 1 of the twins. All other serologic
and routine laboratory test values were normal. The patients were treated with
hydroxychloroquine 100 mg daily, desonide cream once daily, and photoprotection.
The plaques healed in 5 weeks with mild postinflammatory hyperpigmentation. Our
case demonstrates the rare occurrence of disseminated discoid lupus in identical
twins and emphasizes the importance of genetic factors in the pathogenesis of this
disease.
Commercial support: None identified.
Commercial support: None identified.
P8573
Lower vitamin D levels in patients with cutaneous lupus erythematosus
Eugenia Cutillas-Marco, MD, Hospital de la Vega Lorenzo Guirao, Cieza, Spain;
Amparo Fuertes-Prosper, MD, Hospital Universitario Doctor Peset, Valencia,
Spain; Amparo Marquina-Vila, MD, PhD, Hospital Universitario Doctor Peset,
Valencia, Spain; Marıa M. Morales-Suarez-Varela, MD, PhD, University of Valencia,
CIBERESP, Unit of Public Health and Environmental Care, Center for Public
Health Research (CSISP), Valencia, Spain
P7665
Conclusion: We found a high prevalence of vitD insufficiency and deficiency among
patients with cutaneous lupus erythematosus. For that reason, we recommend
screening for deficiency of 25-OH-vitamin D in any person at risk, including all the
diseases where sun avoidance is recommended.
Rowell syndrome: A case of erythema multiformeelike skin lesions in the
setting of preexisting subacute cutaneous lupus erythematosus
Sherry Yang, MD, Henry Ford Medical Center, Detroit, MI, United States;
Chauncey McHargue, MD, Henry Ford Medical Center, Detroit, MI, United States
The term Rowell syndrome (RS) was originally used by Rowell et al in 1963 to
describe the coexistence of erythema multiformeelike (EM-like) skin findings in
patients with cutaneous lupus. To date, there have been \100 total cases of RS
reported in the dermatologic and rheumatologic literature. Although various sets of
diagnostic criteria have been proposed by different groups, the existence of RS as a
distinct clinical entity remains controversial. We describe a case of a 34-year-old
African American female with known subacute cutaneous lupus erythematosus
(SCLE) with positive antinuclear and anti-Ro antibodies, who presented to clinic
with a chief complaint of ‘‘lupus flare’’ following recent decrease in prednisone
dose. Physical examination revealed multiple erythematous arcuate to annular
plaques with dusky centers and overlying flaccid bullae on the trunk and
extremities, as well as buccal and labial erosions. Palms and soles were spared.
Punch biopsy showed full thickness epidermal necrosis consistent with bullous EM.
Direct immunofluorescence was negative. Infectious work-up, complement levels,
sedimentation rate, C-reactive protein, and rheumatoid factor were all unremarkable. Patient was treated with high-dose IV methylprednisolone with significant
improvement in rash and degree of skin tenderness. Because of the morphologic and
histologic overlap between EM and SCLE, several authors have suggested that RS be
considered as a subset of cutaneous lupus rather than a separate disease.
Coincidental occurrence of EM and SCLE has also been proposed, but is less likely.
Unlike traditional EM, lesions in RS have no predilection for acral locations, and are
very rarely associated with identifiable triggers (usually medications rather than
herpes virus or infection). Mucosal involvement is seen in approximately 50% of
cases. Lastly, about 50% to 60% of biopsied EM-like lesions display granular deposits
at the basement membrane zone on direct immunofluorescence. The clinical
implications of this diagnosis remain unclear, and more information is required
regarding the prognosis and management of RS.
Commercial support: None identified.
Commercial support: None identified.
Background: Vitamin D (vitD) is crucial for maintaining the body’s calcium
homeostasis. Its deficiency in progression of cancer and several autoimmune
diseases. It has been shown that the serum levels of vitD are significantly lower in
patients with systemic lupus erythematosus (SLE) compared with control groups.
We wanted to know whether these findings are limited to SLE or if vitD deficiency is
also observable in patients with chronic discoid lupus erythematosus or subacute
cutaneous lupus erythematosus.
Methods: We measured serum levels of 25-hydroxyvitamin D and PTH in 55 cases
and 122 age- and sex-matched unaffected controls; All participants completed a
standardized questionnaire that ascertained demographic characteristics, chronic
diseases, medication, dietary supplements, sun habits, sun holidays, sun-bed use,
and other lifestyle variables that could cause differences in vitD level. Weight and
height were recorded and the body mass index was calculated.
Results: Cases presented darker skin phototype than controls and there were more
smokers among cases. There were more sun worshippers among controls, who
usually used less sunscreen than controls. VitD levels were higher in controls (25.99
6 7.67 vs 19.89 6 8.73; P ¼ .001). Of the 55 tested cases, 52 (94.54%) had serum
vitamin D levels \30 ng/mL, which is the range consistent with insufficiency,
including 6 patients (10.9%) with \10 ng/mL. By contrast, of the 117 controls, 34%
reached the optimal vitamin D levels, 66% presented 10-30 ng/mL and only 1 person
presented vitamin D deficiency (\10 ng/mL). PTH levels were higher in controls
(48.73 6 15.91 vs 34.05 6 17.28, P ¼ .001).
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB59
P8018
P7959
Vitamin D status, photoprotective habits, and oral vitamin D intake among
cutaneous lupus patients
Erin Vickery, Emory University School of Medicine, Department of Dermatology,
Atlanta, GA, United States; Aneesha Thobani, Emory University School of
Medicine, Department of Endocrinology, Atlanta, GA, United States; Laura
DeLong, MD, MPH, Emory University School of Medicine, Department of
Dermatology, Atlanta, GA, United States; Oranan Siwamogsatham, MD, Emory
University School of Medicine, Department of Endocrinology, Atlanta, GA,
United States; Rajini Murthy, MD, Emory University School of Medicine,
Department of Dermatology, Atlanta, GA, United States; Vin Tangpricha, MD,
PhD, Emory University School of Medicine, Department of Endocrinology,
Atlanta, GA, United States
Patients with cutaneous lupus erythematosus (CLE) may be at increased risk for low
vitamin D (vitD) status because of sun avoidant behaviors. This abstract reports some
preliminary results examining vitD status in CLE patients without systemic lupus and
examines the correlation of vitD levels with photoprotective habits and oral vitD
supplementation. Adult CLE subjects were recruited from Emory and Grady
dermatology clinics in the spring of 2012 and 2013. Subjects completed surveys
querying demographics, oral vitD intake, and photoprotective habits (Sun Protection
Habits Instrument [SPHI]: 1-4 scale, higher score meaning higher adherence).
Subjects had serum 25-hydroxyvitamin D (25(OH)D) levels drawn and measured by
magnetic particle-based chemiluminescence immunoassay (CLIA). VitD deficiency
was defined as 25(OH)D\20 ng/mL and insufficiency as 20 and\30 ng/mL. To date,
we have enrolled 15 subjects, 14 of which were female. The mean (SD) age was 48
(11) years. Fitzpatrick skin type was V in 80% of subjects. 14 subjects had discoid
lupus and 1 had subacute cutaneous lupus. The mean serum 25(OH)D level was 22.6
(15.8) ng/mL. 60% were vitD deficient and 20% were vitD insufficient. By total SPHI
score (5 components: sunscreen, shade seeking, shirt with sleeves, hat, sunglasses)
67% of subjects were adherent to photoprotection (SPHI scores 3-4). Of the
individual components, higher adherence was to shade seeking (67%) and to
wearing shirt with sleeves (67%), then poorer adherence to sunscreen use (20%). The
mean serum 25(OH)D level did not statistically significantly differ between photoprotection adherence groups (1-2 vs 3-4) for total and individual SPHI components,
although trended towards significance for shade seeking (adherent; 18.6 [8.8] vs
nonadherent; 30.8 [23.9] ng/mL; P ¼ .16). The mean daily vitD supplement intake
was 525 (774) IUs and the mean daily dietary vitD intake was 269 (238) IUs. Although
the mean serum 25(OH)D level did not differ between oral supplementation groups
([ or ¼ 600 IU/day), the means in both groups were \30 ng/mL. These pilot results
suggest that in CLE patients who tend to avoid the sun (as evidenced by high
adherence to photoprotection, especially shade seeking), even oral vitD supplementation of [600 IU/day may not be enough to reach sufficient serum 25(OH)D
levels. Further research is warranted in this area to determine the relationship
between vitD levels, photoprotection, and vitD supplementation in CLE patients.
A new body moisturizer increases skin hydration among children and
adults with atopic dermatitis symptoms
Eric Simpson, MD, Department of Dermatology, Oregon Health and Science
University, Portland, OR, United States
Commercial support: None identified.
Atopic dermatitis (AD) is a chronic, inflammatory skin disease which is characterized by skin barrier dysfunction. A single-center, 5-day study (N ¼ 30) was
conducted to examine the effectiveness of a body moisturizer (Galderma
Laboratories, L.P., Ft. Worth, Texas) to restore skin barrier function in patients 1855 years of age with a history of active or quiescent AD. After 0.5% SDS-induced
disruption, repeated applications of the body moisturizer over 5 days were
significantly more effective at restoring skin barrier function than spontaneous
recovery on the area being left untreated (P \.05). There was 1 adverse event (AE)
of mild local skin irritation reported in this study. Another multicenter, 28-day study
(N ¼ 127) was conducted to assess the effectiveness of the body moisturizer in
patients 3 years or older with mild or moderate AD and who were being treated with
a topical corticosteroid (TCS). Patients (or parents) were instructed to apply the
body moisturizer to only one side of the body twice daily while continuing their
existing TCS treatment as needed. At day 28, significantly higher skin hydration was
reported on the side receiving the body moisturizer compared to the side with TCS
only (P \.05). The disease severity (EASI score) decreased progressively on both
sides of the body, but the side receiving both the TCS and the body moisturizer had a
more rapid onset of action. No patients discontinued the study because of an adverse
event. Four AEs, which were mild in severity, were deemed probably related to the
study products and included 2 events of stinging and 2 events of burning sensation.
The results from these 2 studies suggest that the application of this body moisturizer
increases skin hydration and relieves AD symptoms by helping to restore the skin
barrier function.
Study funded and poster/editorial support provided by Galderma Laboratories,
L.P.
P7728
DERMATITIS, ATOPIC
P8422
A daily moisturizer and a steroid-free acute therapy emollient cream
reduce the symptoms of atopic dermatitis in babies and children with
mild to moderate eczema lesions.
Teresa M. Weber, PhD, Beiersdorf Inc, Wilton, CT, United States; Alexander
Filbry, PhD, Beiersdorf AG, Hamburg, Germany; Andrea M. Schoelermann, MD,
Beiersdorf AG, Hamburg, Germany; Frank Rippke, MD, Beiersdorf AG, Hamburg,
Germany; Ulrich Scherdin, PhD, Beiersdorf AG, Hamburg, Germany
A novel new sodium hypochlorite formulated wash as an adjunctive
approach to the management of pediatric subjects with moderate to
severe atopic dermatitis colonized with Staphylococcus aureus
Benjamin Bohaty, MD, The University of Texas Health Science Center at Houston,
Houston, TX, United States; Adelaide Hebert, MD, The University of Texas Health
Science Center at Houston, Houston, TX, United States; Amy Paller, MD, MS,
Northwestern University Feinberg School of Medicine, Chicago, IL, United
States; Dennis West, PhD, Northwestern University Feinberg School of
Medicine, Chicago, IL, United States; Gil Abramovici, MD, Northwestern
University Feinberg School of Medicine, Chicago, IL, United States; Kathryn
Durham, MD, The University of Texas Health Science Center at Houston,
Houston, TX, United States
Background: Staphylococcus aureus colonization and subclinical or overt infection
represent common clinical findings in patients with atopic dermatitis (AD) and are
known to contribute to exacerbation of the overall disease state. Moreover, atopic
patients are commonly colonized with S aureus on both lesional and nonlesional
skin. Given the key role of S aureus in triggering the inflammation of AD, adjunctive
measures such as dilute sodium hypochlorite (bleach) baths have been used by
many physicians in an effort to decrease colonization and infection rates and,
consequently, disease severity. A novel gel cleanser containing a very dilute
concentration of sodium hypochlorite (0.006%) designed for use in the bath or
shower, may be a convenient alternative to bleach baths.
Objective: The purpose of this trial was to evaluate the response of AD in infectionprone moderate to severe S aureus-colonized subjects who cleansed with a novel
new sodium hypochlorite formulated wash once daily.
Atopic dermatitis (AD), a condition known for its dry pruritic lesions, is prevalent
among children. Emollient therapy is a cornerstone of managing the disease and
reducing the frequency of flares. Two studies were conducted to evaluate the efficacy
of 2 novel test formulations. The first tested a daily moisturizing cream (DMC)
containing oatmeal, ceramide 3, licochalcone A, and castor seed oil. Reduction of itch
and tolerability were assessed by the investigator (0-3 scale), and skin hydration was
measured by instrumentation. The second study tested an acute therapy cream (ATC)
containing oatmeal, ceramide 3, licochalcone A, and menthoxypropanediol, a cooling
agent. Efficacy of the ATC in providing immediate relief from pruritus and AD
symptoms was assessed. The investigator evaluated tolerability, severity of AD
symptoms (0-3), and AD severity index (ADSI, 0-15); skin hydration was measured
by instrumentation, and a caregiver’s assessment was used. The DMC was tested for 2
weeks with twice daily application on 64 male and female children (3 to 151 months,
36.1 avg) with dry skin and a confirmed history of AD (Hanifin and Rajka criteria), 26
with active lesions. Significant itch reduction was observed for the entire group and
the lesional subgroup. Pruritus in children with lesions was reduced from 1.56 at
baseline (bsl) to 0.69 at week 2 (wk2). Skin hydration was also significantly improved
for nonlesional (29.2 bsl; 41.1 wk 2) and lesional skin (18.28 bsl; 35.03 wk2). The DMC
was well tolerated by all subjects, with observed decreases in skin irritation scores. The
ATC was tested on 29 male and female children with AD lesions (3-147 months, 40.5
avg) for 2 weeks with twice daily application. AD symptoms at wk2 revealed
significant reductions from bsl in erythema (54%), pruritus (65%), and lichenification
(57%), resulting in a 58% overall reduction in ADSI. The ATC also proved efficacious in
the hydration of lesions, 21.1 (bsl) to 35.8 (wk2). In addition, both clinical grading and
the caregiver’s assessment confirmed the ATC was well-tolerated; questionnaire
responses demonstrated the ATC was perceived to be gentle on eczema (97%
agreement), immediately soothing (76%), and effectively moisturizing to the child’s
skin (93%). In summary, the DMC and ATC effectively hydrated AD lesions, reduced
itch, and proved to be well tolerated by babies and children with AD. The ATC
provided immediate relief from pruritus, and reduced AD symptoms and severity.
Results: The cohort was comprised of 24 subjects (54.2% male and with mean age of
9.1 6 8.1 years). Mean change from baseline in the EASI score was 4.29 (SD ¼ 5.4) at
2 weeks (an improvement of 34.1%) and 5.45 (SD ¼ 6.26) at 6 weeks (an
improvement of 43.4%). Mean change from baseline in the VAS score was 12.1
(SD ¼ 23.9) at 2 weeks (an improvement of 30.6%) and 16.5 (SD ¼ 22.8) at 6 weeks
(an improvement of 41.7%).
Conclusion: A novel new sodium hypochlorite formulated wash appears to exert a
positive outcome for S aureus-colonized patients with AD as measured by AD
improvement at 2 and 6 weeks of wash use.
Supported by Beiersdorf Inc.
Sponsored 100% by TopMD Skin Care, Inc.
AB60
Methods: Subjects were recruited from pediatric outpatient dermatology clinics in 2
large urban centers in the United States. S aureus colonization was first confirmed
by positive bacterial culture of skin affected by AD. Assessments occurred at 3 office
visits over a 6-week period (2012-2013) and included Eczema Area and Severity
Index (EASI) and Pruritus Visual Analog Scale (VAS) to assess response to this open
label intervention. AD response to this open label intervention was determined by a
change in EASI and VAS scores from baseline.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8372
P8568
A 3-week moisturization study followed by a 2-week regression phase to
evaluate the efficacy of a triple oat skin protectant cream versus a
ceramide cream on moderate to severe dry skin
Judith Nebus, MBA, Johnson & Johnson Consumer Companies, Inc, Skillman, NJ,
United States; Michael Suero, Johnson & Johnson Malaysai, Petaling Jaya,
Selangor, Malaysia; Warren Wallo, MS, Johnson & Johnson Consumer
Companies, Inc, Skillman, NJ, United States
Background: Flaking, roughness, and pruritus are common problems among
patients with extra dry skin. Daily application of moisturizing creams with
ingredients, such as skin protectants, humectants, and emollients is important to
enhance skin water content and protect the skin barrier. Colloidal oatmeal is a
natural skin protectant that contains a variety of components, including avenanthramides, that bind to the skin to provide a protective barrier. The purpose of this 5week study was to compare the effectiveness of a skin protectant moisturizing
cream containing colloidal oatmeal, oat oil, and avenanthramides (triple oat cream)
with a leading ceramide moisturizing cream in improving moisture content and
barrier function in individuals with moderate to severe xerosis on the lower legs.
Antiinflammatory and immunomodulatory effects of I-modulia, an
Aquaphilus dolomiae extract, on atopic dermatitis in vitro
Marie-Franc¸oise Aries, PhD, Pierre Fabre DermoCosmetique, Toulouse, France;
Clemence Vaissiere, Pierre Fabre DermoCosmetique, Toulouse, France; Helene
Delga, Pierre Fabre DermoCosmetique, Toulouse, France; Marguerite Lev^eque,
Pierre Fabre DermoCosmetique, Toulouse, France; Nathalie Castex-Rizzi, PhD,
Pierre Fabre DermoCosmetique, Toulouse, France; Sandrine Bessou-Touya, PhD,
Pierre Fabre DermoCosmetique, Toulouse, France; Thien Nguyen, PhD, Pierre
Fabre DermoCosmetique, Toulouse, France
Methods: Subjects with moderate to severe xerosis on the lower legs used either the
triple oat cream or ceramide cream twice a day for 21 days (treatment phase). On
days 22 to 34 (regression phase) subjects did not use any treatment moisturizer on
their legs. Transepidermal water loss (TEWL) and moisture content/hydration
(Corneometer) were measured at baseline and various times during the study.
Results: Thirty-five subjects completed the study. Significant improvements from
baseline in TEWL measurements were observed (P \ .05) at all time points
(treatment and regression phases) in groups using either product. However, the
group using triple oat cream had greater improvements in TEWL (P\.05) than those
using the ceramide cream on days 7 and 14. Use of either product, increased leg skin
moisture content significantly from baseline (P \ .05) throughout both the
treatment and regression phases. Consistent with the TEWL results, users of the
triple oat cream had significantly higher leg skin moisture content compared with
users of the ceramide cream at all time points during the treatment phase. Clinical
evaluations for roughness showed a significant improvement from baseline at all
time points (treatment and regression) for both treatment groups.
Conclusions: Both the triple oat cream and ceramide cream improved skin barrier
function (TEWL) and moisture content compared with baseline in individuals with
moderate to severe xerosis on the lower legs. However, the triple oat cream
provided signifantly greater benefits during this clinical trial than did the ceramide
cream.
Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex
pathophysiology, including genetic, immunologic and environmental factors interactions, and characterized by allergic inflammation, barrier disruption, and
pruritic lesions. Keratinocytes which are active immunologic cells with major
control over AD inflammation by means of cytokine/chemokine production
contribute to the disease phenotype development. Likewise, TH1, TH2, TH17 cells
which are commonly observed in AD lesions are postulated in the disease process.
Emollient application makes the use of topical potent immune modulatory agents
logical therapeutic consideration. The aim of the present study was to evaluate Imodulia, an original biologic extract from culture of Aquaphilus dolomiae, isolated
from Avene Spring Thermal Water microflora, on different immune inflammatory
cell models. Firstly, inflammatory mediators gene expression was assessed in Normal
Human Keratinocytes (NHK) stimulated by the association polyI:C+IL4+IL13+TNFa
and performed by Q-PCR 32 genes array. Secondly PAR-2 (protease-activated
receptor-2) activity was assessed in NHK stimulated by trypsin and performed by
Ca2+ flux signals monitoring. Finally TH1, TH2, TH17 cytokines basal production
was assessed on CD4+ lymphocytes by 12-plex Luminex technology. Our results
showed that I-modulia inhibited gene expression of numerous mediators including
TSLP, IL18, IFNb1, RANTES, MCP3, TARC, MIP-3a, MDC, IL4R, and induced
involucrin, psoriasin, RNase7 gene expression; I-modulia also inhibited the PAR-2
activation and the TH1, TH2, TH17 cytokines production (IL2, IFNg/IL4, IL5,
IL13/IL17, respectively). Together, the present data support the high regulator
activity of I-modulia, an A dolomiae extract, on keratinocyte inflammatory and
lymphocyte immune responses, and reveal its powerful interest in topical
preparations designed for the regulation of AD immune inflammatory pathology.
Commercial support: None identified.
Sponsored 100% by Johnson & Johnson Consumer Companies, Inc.
P7926
Atopic dermatitis in adults: Association of impaired of CD38 and CD69
expression and eosinophilia.
Tiago de Oliveira Titz, MMSc, University of S~ao Paulo Medical School, S~ao Paulo,
Brazil; Camila de Lollo, MMSc, University of S~ao Paulo Medical School, S~ao Paulo,
Brazil; Maria Notomi Sato, PhD, University of S~ao Paulo Medical School, S~ao
Paulo, Brazil; Raquel Leao Orfali, MD, University of S~ao Paulo Medical School, S~ao
Paulo, Brazil; Valeria Aoki, MD, PhD, University of S~ao Paulo Medical School, S~ao
Paulo, Brazil; Vanessa Gonc¸alves dos Santos, MMSc, University of S~ao Paulo
Medical School, S~ao Paulo, Brazil
Objective: The aim of this study was to evaluate the expression of activation markers
on eosinophils from peripheral blood of atopic dermatitis (AD) patients and
correlate them with disease severity.
P8062
Antiinflammatory activity of colloidal oat (Avena sativa)
MIchael Southall, PhD, Johnson & Johnson Consumer Companies, Inc, Skillman,
NJ, United States; Karien Rodriguez, PhD, Johnson & Johnson Consumer
Companies, Inc, Skillman, NJ, United States; Khalid Mahmood, PhD, Johnson &
Johnson Consumer Companies, Inc, Skillman, NJ, United States; Kurt
Reynertson, PhD, Johnson & Johnson Consumer Companies, Inc, Skillman, NJ,
United States; Michelle Garay, MS, Johnson & Johnson Consumer Companies,
Inc, Skillman, NJ, United States; Simarna Kaur, PhD, Johnson & Johnson
Consumer Companies, Inc, Skillman, NJ, United States
Oats (Avena sativa) are one of the earliest domesticated crops, valued as food and
medicine for centuries. Oatmeal baths, plasters, and extracts have a long history of
use as a skin soothers and topical antiinflammatory agents. Colloidal oatmeal—finely
ground whole oat kernels—is a monographed ingredient in the US FDA Skin
Protectant monograph. Oats contains a high oil content, and are a rich source of
unsaturated omega-3 linoleic and omega-6 linolenic acid triglycerides, mixed
tocopherols and tocotrienols, beta-glucan, phenolics, starches, and proteins.
Despite centuries of use many of the biochemical mechanisms that make colloidal
oats beneficial to the skin remain unclear. Therefore, this study investigated the
mechanisms of colloidal oat activity on human keratinocytes. Extracts of colloidal
oat were found to significantly attenuate the UV-induced production of reactive
oxygen species from primary human keratinocytes. Furthermore, our studies
determined that extracts of colloidal oat reduced the levels of the proinflammatory
mediator, IL-8, in a UV-induced inflammation model of keratinocytes. Taken
together, these results demonstrate that colloidal oats have direct antioxidant and
antiinflammatory activity which may provide the therapeutic effect for dermatologic formulations containing colloidal oats.
Methods: This study enrolled patients with AD from Hospital das Clınicas, University
of S~ao Paulo Medical School, diagnosed according to Hanifin and Rajka criteria. Out
of the 12 patients included in the study, 2 were males and 10 females, aged between
21 and 61. Twenty healthy controls, aged between 24 and 53 years, 8 males and 13
females were also enrolled. Severity of AD was established according to EASI
(Eczema Area and Severity Index, patients graded as mild (58.3%), moderate (16.6%)
and severe (25%). Eosinophils (lineage cocktail 1- CCR3+) from peripheral blood
were analyzed for CD38, CD69, CD23, and CD62L expression by flow cytometry
(LSR Fortessa, BD Biosciences) and analysis was performed using Flow Jo 7.5.6
software.
Results: Our findings revealed an increased frequency of CCR3+ eosinophils, and
upregulation of CCR3 medium fluorescence intensity (MFI) in AD individuals, when
compared to controls. As for the CD69 and CD38 expression, we detected an
increased frequency in eosinophils, with diminished medium fluorescence intensity
(MFI) in AD individuals, when compared to controls. No significant difference in
CD23 and CD62L expression on eosinophils were detected in the analyzed groups.
The findings were not associated with AD severity.
Sponsored 100% by Johnson & Johnson Consumer Companies, Inc.
Commercial support: None identified.
Background: Atopic dermatitis is a chronic, recurrent inflammatory disease, with
prevalence around 10% to 20% in children and 1% to 3% in adults. Elevated serum
levels of eosinophils are frequently observed in AD patients, and may be implicated
in the pathogenesis of this skin condition.
Conclusion: Eosinophilia is a hallmark of atopic dermatitis; however, augmented
number of eosinophils may not reflect a normal functional profile of these
inflammatory cells, once it is associated with decreased activation of CD38 and
CD69 eosinophil markers.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB61
P8719
P8701
Atopic dermatitis in adults: Design and validation of a specific burden
questionnaire
Alain Taieb, MD, Groupe Hospitalier Saint Andre, Bordeaux, France; Charles Taieb, MD,
PFSA, Paris, France; Franck Boralevi, Groupe Hospitalier Saint Andre, Bordeaux,
France; Khaled Ezzedine, MD, Groupe Hospitalier Saint Andre, Bordeaux, France;
Stephanie Merhand, NP, Association Franc¸aise de l’Eczema, Redon, France
Background: Atopic dermatitis (AD) is a common skin condition, even in adults. On
the contrary of quality of life questionnaires, the notion of individual burden
associated with a disease has been introduced to determine the ‘‘disability’’ in the
broadest sense. Previously, a self-administered specific burden questionnaire for
families of children affected by AD has been validated (ABS-F). The aim of the current
study was to develop and validate the Atopic dermatitis Burden Scale questionnaire
for Adults (ABS-A) following Classical Test Theory method (CTT).
Method: The questionnaire was developed by a working group composed of
individuals with expertise in PRO development, dermatologists, and patients from
patients’ association. From the items of the ABS-F, the team assessed the need to
adapt or not the items for the ABS-A. Subsequently, this questionnaire was sent to
900 individuals with AD. ABS-A was refined via exploratory factor analysis (EFA).
Internal consistency was determined by calculating the Cronbach ?, concurrent
validity by calculating the Spearman rank coefficient correlation between ABS-A,
SF-12 and Dermatology Life Quality Index (DLQI) questionnaires. Discriminant
validity was analyzed according to the severity degrees of AD assessed by the Patient
Oriented SCORing index of AD (PO-SCORAD) scale.
Results: Among the first 284 subjects who sent back their questionnaires, 128
individuals filled out the ABS-A entirely and were then evaluated. 68.8% of them were
men and almost 50% of them were aged between 35 and 64 years old. Based on the
results of the EFA, 1 item was removed because of cross-loading on factors.
Consequently, the questionnaire consisted of 18 items grouped into 4 domains. ABS-A
showed good internal coherence (Cronbach ?: 0.89). ABS was significantly correlated to
both components of the SF-12 (r(PCS) ¼ -0.36, P \.0001; r(MCS) ¼ -0.52, P \.0001).
A higher coefficient correlation has been found between ABS-A and DLQI (r ¼ 0.78;
P \.0001). Significant differences between severity degrees of AD have been shown.
Conclusion: These preliminary results suggest the validity of the ABS-A questionnaire. However, since recruitment of patients is not achieved, performing analyses of
the other stages of CTT, and confirmatory factor analysis or rash analysis are
warranted. Comparison between both methods may be valuable.
Clinical development program of a new dermocosmetic range of products
containing I-modulia (Aquaphilus dolomiae extract) in atopic dermatitis
Therese Nocera, MD, Clinical Skin Research & Development Center, Hotel Dieu,
Pierre Fabre Dermo-Cosmetique, Toulouse, France; Ana Beatris Rossi, MD,
Clinical Skin Research & Development Center, Hotel Dieu, Pierre Fabre
Dermo-Cosmetique, Toulouse, France; Valerie Mengeaud, Clinical Skin
Research & Development Center, Hotel Dieu, Pierre Fabre Dermo-Cosmetique,
Toulouse, France
As dermatologists, we look for robust data to recommend products to our patients.
Regarding drugs, we can count on registration data, which include mandatory
randomized, double-blind controlled studies following specific guidelines and good
clinical practice. However, for cosmetics, there is no ‘‘registration,’’ no guidelines,
and manufacturers are not obliged to perform clinical studies. Therefore, there is a
diversity of available data supporting cosmetic products and a huge variability on
type and amount of studies, as well as the quality of data and results. Atopic
dermatitis (AD) is a chronic relapsing condition and emollients are the mainstay
treatment. Many emollients have been studied and demonstrated their benefit in the
maintenance phase. Few have been evaluated in randomized, double-blind,
multicenter controlled trials versus excipient. Recently, a biologic extract from a
culture of Aquaphilus dolomiae, isolated from a spring thermal water microflora,
was registered as an active ingredient and in vitro data demonstrate its action on
different immune inflammatory cell models. We present the clinical development
program for a new range of products containing this new active ingredient,
including [1100 subjects, adult and paediatric population, 3 months and older. The
tolerance of a product is crucial for this type of product, considering that patients
with AD present a skin barrier defect and are more sensitive to topical products. The
clinical program followed a sequential approach, testing the product first in healthy
adult skin (ROAT and HRIPT tests), followed by atopic adult skin and finally atopic
paediatric skin. All studies were supervised by a board-certified dermatologist.
Studies in the paediatric population included evaluation by both dermatologists and
paediatricians. Efficacy was measured by clinical and subjects or caregivers’
evaluations (IGA, SCORAD and PO-SCORAD), individual signs and symptoms,
instrumental evaluations (pH, corneometry, stripping, TEWL), biologic measurements, and quality of life questionnaires (CLQI and DLQI). The results of these
studies demonstrated a very good tolerance profile and the benefit of the use of
these products in the management of AD in both adult and pediatric population with
mild to moderate atopic dermatitis, when applied both on lesional and nonlesional
skin, especially during the maintenance phase.
Supported by Eau Thermale Avene.
Sponsored 100% by Pierre Fabre Dermo-Cosmetique, France.
P8000
Clinical and biometrologic evaluation of a novel emollient balm containing an
Aquaphilus dolomiae extract in 1- to 4-year-old children suffering from atopic
dermatitis: International, multicenter, randomized versus control group study
Annalisa Patrizi, MD, PhD, Department of Dermatology, Bologna University, Bologna,
Italy; Adeline Bacquey, Skin Applied Research Center, Pierre Fabre Dermocosmetique, Toulouse, France; Anne Marie Schmitt, MD, PhD, Skin Applied
Research Center, Pierre Fabre Dermo-cosmetique, Toulouse, France; Catherine Jean
Decoster, PharmD, PhD, Pierre Fabre Dermo-cosmetique, Toulouse, France; Chloe
Phulpin, PharmD, Skin Applied Research Center, Pierre Fabre Dermo-cosmetique,
Toulouse, France; Jennifer Theunis, MD, Skin Applied Research Center, Pierre Fabre
Dermo-cosmetique, Toulouse, France; Valerie Mengeaud, PhD, Skin Applied Research
Center, Pierre Fabre Dermo-cosmetique, Toulouse, France
Introduction: Use of emollient skin care products is widely recommended in the
atopic dermatitis (AD) care between flares, in order to hydrate the skin and restore
the skin barrier. This clinical study has been set up in order to evaluate the efficacy of
a novel emollient balm on clinical parameters (SCORAD, xerosis and pruritus) and
on the restoration of skin barrier (transepidermal water loss [TEWL]) in children
from 1 to 4 years old.
Methods: Children with mild AD have been enrolled in an international, multicenter,
open, randomized versus control group study. Half subjects were randomized in a
group where they should apply, twice a day during 28 days, an emollient balm
containing Aquaphilus dolomiae extract, whose efficacy has been demonstrated in
vitro on inflammation, innate immunity, and pruritus targets. A hygiene product was
also given. The other half of subjects was randomized in a control group, and should
only use the hygiene product. The following parameters were assessed at baseline,
and after 14 and 28 days: SCORAD, xerosis, pruritus, TEWL. Tolerance was also
assessed after 14 and 28 days of use.
Results: Fifty-four children aged 2.5 6 1.0 years whose SCORAD was 11.70 6 3.15
have been included in the study. After 28 days, compared to baseline, a significant
difference is observed in the favor of emollient group, on SCORAD (-48% in
emollient group vs. -20% in control group, P ¼ .0009) and pruritus (-75% vs. -36%;
P ¼ .0599). Xerosis was less severe in the emollient group (P ¼ .0562). TEWL
decreases more in the emollient group (-34% vs. +5%; P ¼ .794). In the emollient
group, compared to baseline, a significant decrease is observed after 14 days on
SCORAD (-36%; P\.0001), pruritus (-48%; P ¼.0001), xerosis (P ¼.0001), and TEWL
(-32%; P ¼ .0448). This decrease is still significant for all these parameters after 28
days. Subjects completed the study with a mean SCORAD equal to 6.09 6 2.42.
Emollient balm has been well tolerated by the patients.
Discussion: This controlled randomized trial demonstrates the interest of the novel
emollient balm for the improvement of clinical signs of AD, in particular pruritus,
parameter which can impede the most the quality of life of patients suffering from
AD. The restoration of skin barrier has been objectively demonstrated thanks to
TEWL measurement.
Conclusion: This study shows that a twice-daily application of the novel emollient
balm in children with mild AD quickly and significantly improves SCORAD, xerosis,
and pruritus and restores the altered skin barrier.
Sponsored 100% by Pierre Fabre Dermo-cosmetique.
AB62
P7670
Evaluation of circulating chemokines in patients with inflammatory
dermatoses (atopic dermatitis and psoriasis) and autoimmune blistering
diseases.
Alessandra Anzai, MD, University of S~ao Paulo School of Medicine, S~ao Paulo,
Brazil; Bomi Hong, MD, University of S~ao Paulo School of Medicine, S~ao Paulo,
Brazil; Natasha Szwako, MD, University of S~ao Paulo School of Medicine, S~ao
Paulo, Brazil; Raquel Orfali, MD, University of S~ao Paulo School of Medicine, S~ao
Paulo, Brazil; Valeria Aoki, PhD, University of S~ao Paulo School of Medicine, S~ao
Paulo, Brazil
Background: Atopic dermatitis (AD) is a chronic, inflammatory, pruritic skin disease
with a complex pathogenesis that includes environmental triggers, immunologic
abnormalities, and/or skin barrier defects. Chemokines are chemotactic cytokines
that modulate the immune response, targeting certain cell populations in inflammatory diseases.
Objectives: The aim of this study was to determine the profile of circulating
chemokines: CXCL10, CCL2, CXCL9, CXCL8, and CCL5 from patients with inflammatory and autoimmune dermatoses (atopic dermatitis, psoriasis, and autoimmune
blistering diseases).
Methods: All the chemokines but CCL5 were tested by flow cytometry. Twenty-eight
patients with atopic dermatitis (aged 18-48 years) were compared with patients with
autoimmune bullous diseases (BD, n ¼ 29), psoriasis (PSO, n ¼ 10), and healthy
controls (HC, n ¼ 33).
Results: In the sera of atopic dermatitis patients, we detected augmented levels of
CXCL10, in comparison to BD and HC, high levels of CXCL9, when compared to HC,
and lower levels of CXCL8, when compared to BD. Regarding AD severity, there was
no significant difference in the chemokine profile. In the BD group, high levels of
CCL2, CXCL9, and CXCL8 were seen, in comparison to HC. In psoriasis, there was
no significant increase in any serum chemokine levels. Circulating CCL5 did not
show any difference in all the analyzed groups.
Conclusions: Our findings suggest that CXCL10 is a constant, potential serological
biomarker of the Th1-related inflammatory processing atopic dermatitis, and is not
related to the severity of the disease.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P7637
P8658
Hair zinc levels and efficacy of oral zinc supplementation in patients with
atopic dermatitis
Eunjin Kim, MD, Hanyang University Hospital, Seoul, South Korea; Hyunwoo
Kim, MD, Hanyang University Hospital, Seoul, South Korea; Jeongeun Kim, MD,
PhD, Hanyang University Hospital, Seoul, South Korea; Jooyeon Ko, MD, PhD,
Hanyang University Hospital, Seoul, South Korea; Seorye Yoo, MD, PhD, Leejiham
Dermatologic Clinic, Seoul, South Korea; Youngsuck Ro, MD, PhD, Hanyang
University Hospital, Seoul, South Korea
Background: Zinc is an essential trace element that serves many biologic functions,
and it has been reported that serum zinc level in atopic dermatitis (AD) patients is
lower than the control group. However, there is no available guideline regarding
zinc supplementation in AD patients. The aim of this study was to evaluate the hair
zinc status of patients with AD and to determine the usefulness of oral zinc
supplementation in AD patients with low hair zinc level.
I-modulia, an Aquaphilus dolomiae extract, stimulates innate immune
response through Toll-like receptor activation
Marie-Franc¸oise Aries, PhD, Pierre Fabre DermoCosmetique, Toulouse, France;
Helene Duplan, PhD, Pierre Fabre DermoCosmetique, Toulouse, France; Helene
Hernandez-Pigeon, PhD, Pierre Fabre DermoCosmetique, Toulouse, France;
Marie Florence Galliano, PhD, Pierre Fabre DermoCosmetique, Toulouse,
France; Nathalie Castex-Rizzi, PhD, Pierre Fabre DermoCosmetique, Toulouse,
France; Sandrine Bessou-Touya, PhD, Pierre Fabre DermoCosmetique, Toulouse,
France; Thien Nguyen, PhD, Pierre Fabre DermoCosmetique, Toulouse, France
Methods: We collected hair samples from 58 patients with AD and 43 normal
controls and checked the hair zinc level. Also, we investigated the efficacy of oral
zinc supplementation on AD patients with low hair zinc level by comparing the 2
groups: group A with zinc supplementation and group B without zinc supplementation. We evaluated the Eczema Assessment Severity Index (EASI) score, transepidermal water loss (TEWL), visual analogue scale (VAS) score for pruritus, and
sleep disturbance.
Results: Approximately 71% of the patients with AD patients and 42% of the controls
had low hair zinc levels (P ¼.003). The statistically significant decrease in mean hair
zinc levels was observed in AD patients (130.9 g/g) compared with controls (113.1
g/g; P ¼ .004). After 8 weeks of treatment, a change of hair zinc level showed
significant increase in group A (P \.001). Also, EASI score, TEWL, and VAS score for
pruritus improved significantly in group A compared with group B (P ¼ .044,
P ¼ .015, P \ .001, respectively). VAS score for sleep disturbance showed
improvement in group A, but it was not statistically significant.
Conclusions: We found that number of hair zinc deficiency was higher and the mean
hair zinc level was lower in AD group than the control group. In AD patients with
low hair zinc levels, clinical improvement was observed by oral zinc supplementation. This present study has a significant value as a preliminary study that explains
the correlation between AD and hair zinc level and clinical effectiveness of oral zinc
supplementation in AD with low hair zinc level.
Commercial support: None identified.
Atopic dermatitis (AD) is a highly chronic relapsing inflammatory skin disease
characterized by skin barrier dysfunction occurring through both genetic and
acquired mechanisms, and associated to immune response alteration. The innate
defective immune response in AD patients has been shown to enhance susceptibility to skin infection, in particular by Staphylococcus aureus; moreover, impaired
innate mechanisms, such as pattern recognition receptors (PRRs) and antimicrobial
peptides (AMPs) lead to impaired recognition of microbial components. A polymorphism in the Toll-like receptor-2 (TLR-2) gene with AD has been reported and
linked to these functional impairments. As well, the production of AMPs has been
reported to be impaired in AD. In this way, the aim of this study was to evaluate an
original biological extract named I-modulia from culture of Aquaphilus dolomiae,
isolated from Avene spring thermal water microflora, on TLRs activation and on
AMPs expression. Activation of TLR-1 to TLR-10 by I-modulia was assessed on
recombinant HEK-293 cell lines which functionally overexpress each TLR protein
and SEAP gene reporter. Expression of AMPs was assessed on normal human
keratinocytes incubated with I-modulia before mRNA quantification by Quantigene
technology. Our results showed that expression of 3 AMPs, hBD-2, cathelicidin, and
psoriasin is up-regulated by I-modulia. Moreover, preincubation of TLR-2, -4, and -5
blocking antibodies suggested that I-moduliaeinduced AMP expression is mediated
through TLR-5. The stimulation efficacy of I-modulia on epidermal AMP was further
demonstrated on a full-differentiated reconstructed epidermis. Last, we analyzed the
activity of I-moduliaecontaining cream, after topical applications onto the surface of
human reconstructed epidermis. I-moduliaecontaining cream specifically induced
higher expression of hBD2, hBD3 and psoriasin as compared to the placebo cream.
Together, the present data support the notable activity of I-modulia, an A dolomiae
extract, on innate immunity by TLR-2, -4, and -5 activation, and by AMPs induction
via mainly TLR-5 activation. Because stimulation of innate immune response is
involved in the restoration of epidermal integrity in AD through TLR activation, our
data are of major interest for AD treatment strategy.
Commercial support: None identified.
P7604
Head and neck dermatitis got you scratching your head? Try itraconazole
Jason Mathis, The Ohio State University College of Medicine, Columbus, OH,
United States; Benjamin Kaffenberger, MD, The Ohio State University Wexner
Medical Center, Division of Dermatology, Gahanna, OH, United States; Matthew
Zirwas, MD, The Ohio State University Wexner Medical Center, Division of
Dermatology, Gahanna, OH, United States
Background: Facial dermatoses, including seborrheic dermatitis, head and neck
dermatitis (HND), allergic contact dermatitis, and atopic dermatitis (AD) may be
difficult to differentiate, even for experienced dermatologists. Patients with head
and neck dermatitis likely represent patients with atopic dermatitis driven by
Malassezia yeast and similar to seborrheic dermatitis, it may respond to itraconazole
and other -azole antifungals.
P8421
Conclusion: Itraconazole and other -azole antifungals may be an effective treatment
for adult patients with AD with a prominent facial component or that appears more
inflammatory or extensive than characteristic seborrheic dermatitis. In our limited
cohort, it was well tolerated, although use of itraconazole was limited by cost in
multiple patients.
Impact of cleanser, water temperature, and rinse time on skin condition
Stacy Hawkins, PhD, Unilever R&D, Trumbull, CT, United States; Anat Shiloach,
PhD, Unilever R&D, Trumbull, CT, United States; Anthony Cece, MS, Unilever
R&D, Trumbull, CT, United States; K. P. Ananthapadmanabhan, PhD, Unilever
R&D, Trumbull, CT, United States; Vickie Foy, Unilever R&D, Trumbull, CT,
United States
Irritation potential with daily cleansing is influenced by a variety of factors,
including the overall mildness of the cleanser, cleanser pH, water temperature,
duration of washing, water hardness, etc. Although the recommendation to avoid
very high temperatures during washing is well accepted, there is little evidence
available on the impact of different regimen factors on skin condition. Much of the
work to date has been on harsh surfactant systems, and not linked with realistic
consumer usage shower temperatures. Consumer studies were conducted to
measure the range of water temperatures and duration of showering in the United
States. A series of clinical studies was then conducted to model the impact of
different factors on skin health. An earlier report showed that washing with the
average temperature resulted in better skin condition compared to the low
temperature range of consumer usage. The goal of this research was to understand
the effects of temperature (across full consumer usage span), rinse time, and
cleanser mildness under realistic consumer usage settings in subjects with moderate
clinical dryness. Approximately 25 healthy female subjects (per study), ages 20-59,
provided informed consent to participate in IRB-approved leg wash studies. All
studies were conducted in severe winter conditions in Winnipeg, Canada. Two test
products were randomly applied to each leg: an ultramild lipid-rich moisturizing
body wash with glycinate (LBW) compared to a regular (REG) body wash (no
moisturizers and harsher surfactant). The wash temperatures and rinse times were
varied across studies to determine effects on skin condition. Expert visual evaluation
of dryness, transepidermal water loss (TEWL), exfoliation, and skin hydration
measurements were obtained at baseline and throughout the studies. The LBW was
significantly milder compared to the REG cleanser in all studies. The average
temperature of consumer usage was milder than both the low and high temperature
ranges, and the shorter rinse time was also milder. This repeats observations from a
previous study comparing the average and low temperatures, and is contrary to the
conventional belief that lower temperature is always better for skin. Potential
mechanisms include enhancement of exfoliation of dry flakes and/or better removal
of surfactants at the average consumer usage temperature. From this research, it is
clear that the use of a milder cleanser is better for skin under varying temperature
and rinse conditions.
Commercial support: None identified.
Sponsored 100% by Unilever R&D.
Objective: We evaluated patients recently referred to our contact dermatitis center
for patch testing, had irrelevant results, and were treated with itraconazole or
substitute -azole for HND.
Methods: We queried the electronic medical records from our institution for patients
that were referred for patch testing, were given the diagnosis of AD, and were
treated with itra-, keto-, or fluconazole between 2011 and the present. Descriptive
data and odds ratios were calculated.
Results: Thirty-five patients were diagnosed with AD and treated with an -azole since
January 2011. Exclusions were performed on 11 patients: 5 for the treatment of
incidental tinea nigra or pityrosporum folliculitis, 4 for lack of follow-up, and 2 who
had previously been treated with itraconazole for HND. The average age of the
remaining 24 patients was 44; the majority was white and female. Age of
development of any dermatitis was evenly distributed. Most patients noted their
characteristic flare beginning during the teenage, young adult, or adult life. Most of
these cases had previously been treated with systemic steroids. Of the 24 cases, all
had some involvement of the head and neck, and 17 responded to treatment. The
mean time on an -azole was 8 months, with a mean overall follow-up of 10 months.
Discontinuation because of adverse events occurred in 1 patient who was successfully rechallenged.
Limitations: This was a retrospective analysis, from a single institution, of a limited
number of patients. We attempted to treat all of these patients with itraconazole.
Because of cost limitations, some patients required alternate -azole substitutions.
Patients were not scored using either investigator- or patient-validated scoring
systems.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB63
P8424
P8032
Improving the quality of skin barrier function with PPAR-activating
technology
Stacey Demento, PhD, Unilever R&D, Trumbull, CT, United States; Brian
Dobkowski, Unilever R&D, Trumbull, CT, United States; Hasiba Pehratovic, MS,
Unilever R&D, Trumbull, CT, United States; Jaime O’Leary, Unilever R&D,
Trumbull, CT, United States; Jennifer Huertas, MS, Unilever R&D, Trumbull,
CT, United States; Kristopher Kalleberg, Unilever R&D, Trumbull, CT, United
States; Stacy Hawkins, PhD, Unilever R&D, Trumbull, CT, United States
The nuclear hormone receptors, peroxisome proliferator-activated receptors
(PPARs), have been shown to play a major role in processes related to overall
barrier maintenance including: homeostasis, keratinocyte differentiation, and
inflammation. Once activated by ligands consisting of fatty acids and their
derivatives, PPARs form heterodimers with retinoid X receptors and regulate the
expression of profilaggrin and genes related to lipid metabolism, among others. Here
we identified 12-hydroxystearic acid (12-HSA) as a pan-agonist of the 3 distinct PPAR
isoforms, all of which are expressed in the epidermis. The goal of this research was
to study the in vivo improvements to skin barrier after topical treatment with
12-HSA. White female subjects with moderately dry skin, ages 18-65 years, were
provided informed consent to participate in institutional review boardeapproved,
double-blind, vehicle-controlled paired application studies. Study personnel applied
the test product daily for 4 weeks, followed by 1 week of regression with no
moisturizers applied. Significant improvements in the skin barrier condition were
observed after product application and regression from 12-HSA in full moisturizing
formulations over the occlusive and humectant effects of petrolatum and glycerin
(without 12-HSA), respectively. The permeability of the skin decreased 1.3 times
over the vehicle control and 3.6 time over no treatment after 3 weeks of use. Higher
levels of NMFs were measured in the stratum corneum after treatment with the 12HSA formulation. In a separate study, 12-HSA in a simple formulation was applied
under occlusive patches over 3 weeks, and was found to result in an increase in the
thickness of the granular layer over the vehicle control, as analyzed by histology of
the epidermis after treatment. Lastly, the percutaneous absorption of 12-HSA and the
delivery into the viable epidermis showed good agreement with in vivo clinical
benefits in skin barrier condition.
Oral tacrolimus in treatment of severe atopic dermatitis
Jack Short, MD, George Washington University, Washington, DC, United States;
Alison Ehrlich, MD, MHS, George Washington University, Washington, DC,
United States; Kerian Dodds, George Washington University, Washington, DC,
United States
Sponsored 100% by Unilever R&D.
Objective: To exhibit a case of oral tacrolimus used in a patient with refractory
atopic dermatitis.
Background: Tacrolimus, a calcineurin inhibitor immunosuppressant, is a drug
widely used in the prevention of organ transplant rejection. Off-label, it has seen a
variety of uses, including the treatment of psoriasis, Behc¸et disease, and pyoderma
gangrenosum. In its topical ointment form, tacrolimus is approved for the treatment
of moderate to severe atopic dermatitis, and has become a well-known nonsteroid
therapy. Oral drugs, such as cyclosporine, are effective in atopic dermatitis, but
carry a long-term risk of nephrotoxicity.
Case report: A 25-year-old white woman presented with chronic severe atopic
dermatitis of the hands, upper arms, and upper thighs. Patch testing was conducted
to rule out allergic contact dermatitis. She had previously used topical steroids with
little relief. Before consultation, outside dermatologists had treated her with pulse
oral corticosteroids. Her medical history was significant for seasonal allergies and
sinusitis. Oral cyclosporine therapy was initiated, but then switched to oral
tacrolimus for long-term therapy. Dosing was calculated using 0.15 mg/kg/day.
Tacrolimus was initiated at 3 mg po BID and then titrated up after 5 weeks to 3 mg
qAM and 4 mg qhs. Significant clearance at the 5-week and 2-month appointments
was noted, and patient reported no adverse effects.
Discussion: Oral tacrolimus has a more desirable side effect profile than previous
drugs used in the systemic treatment of atopic dermatitis. Cyclosporine has
consistent evidence of effectiveness in atopic dermatitis, but is significantly more
nephrotoxic than tacrolimus. While there are little data addressing the dose of oral
tacrolimus for dermatologic use, previous studies for psoriasis used dosing of 0.05 to
0.15 mg/kg/day, significantly less than the 0.1 to 0.4 mg/kg/day used for transplant
patients. With such an improvement in our case, who had previously failed topical
therapies, tacrolimus may be a promising nonsteroidal systemic treatment for atopic
dermatitis.
Conclusion: Tacrolimus may yield promising results in patients with severe atopic
dermatitis, while avoiding the adverse effects of oral corticosteroids and cyclosporine. While less nephrotoxic, the lack of use of tacrolimus in dermatology may be
related to limited experience with this drug in dermatology training programs.
Commercial support: None identified.
P8407
Quality of life impact from a skin care regimen on adult eczema sufferers
Vickie Foy, Unilever R&D, Trumbull, CT, United States; Jeff Wolcheski, Unilever
R&D, Trumbull, CT, United States; Jessica Krisiak, Unilever R&D, Trumbull, CT,
United States; Lara Rafiee, Unilever R&D, Trumbull, CT, United States; Stacy
Hawkins, PhD, Unilever R&D, Trumbull, CT, United States
P8289
Oat (Avena sativa) extracts are frequently used in dermatologic treatments to
reduce irritation and improve dry skin. Extensive clinical trials have demonstrated
the efficacy of formulations containing oats for skin; however, few studies have
determined the mechanisms for how oats produce these benefits for skin. In the
present study, we demonstrate that a lipid extract isolated from oats was able to
induce activation of the peroxisome proliferator-activated receptors (PPAR) PPAR?
and b/d receptors in human keratinocyte cell. PPARs are transcription factors
which, upon activation increase the expression of differentiation proteins and lipid
synthesizing enzymes in skin. The PPAR activity was confirmed by the increased
expression of the PPAR direct target genes, such as ANGPTL4, PLIN2, and CPT1A in
primary human keratinocytes treated with oat oil. Consistent with previous studies
on PPAR activation, treatment with oat oil resulted in a significant upregulation of
differentiation marker genes, such as involucrin and transglutaminse-1. In addition,
we confirmed the increased ceramide synthetic gene expression as b-glucocerebrosidase (GBA) and sphingomyelinases3 (SMPD3) and the intracellular ceramide
transporter, ABCA12. Finally, treating human keratinocytes with oat oil was found to
increase production of ceramide levels up to 3 fold compared to untreated, which is
consistant with PPAR activation. In summary, we found a novel mechanism that
explains the skin benefits of oat oil via stimulation of keratinocyte PPAR? and b/d,
which could increase differentiation and ceramide synthesis resulting in an
improved epidermal barrier.
Atopic eczema is an intensely pruritic cutaneous inflammatory condition that is
exacerbated by irritants, such as cleansing surfactants. Typical skin care recommendations for eczema sufferers include using a mild cleanser followed by a good
moisturizer. It was therefore of interest to understand the impact on quality of life
(QOL) with a daily skin care regimen comprised of a mild, moisturizing body wash
and lotion specifically designed for eczema sufferers. Thirty-two adult panelists
(9 male/23 female) with mild to moderate eczema were enrolled in a multisite,
IRB-approved 4-week body wash and lotion regimen compatibility study, with
dermatologist assessment of eczema condition using the standardized Eczema Area
and Severity Index (EASI). Eligible panelists must have been on their current
treatments for eczema for at least 3 months, and daily moisturizer users. Panelists
replaced their normal cleansers and lotions with the test products in unbranded
packages. Self-perception surveys and a validated QOL survey were completed by
panelists (Dermatology Life Quality Index, or DLQI Score) at baseline and after 2 and
4 weeks. The DLQI survey is comprised of 9 individual questions, and an overall
score is tabulated to indicate total impact on quality of life factors related to impact
on work, social, self-consciousness, and leisure activities (from no effect to
extremely large effect). The moisturizing body wash and lotion were found to be
suitable for use in panelists with mild to moderate eczema and compatible with their
treatments, as assessed by the EASI score. The clinical visual dryness on lesion sites
was also significantly reduced. The regimen was perceived by the panelists to
significantly improve sensations caused by eczema, such as itch, soreness, sting,
roughness, overall feel, etc. at all weeks. The DLQI survey results showed significant
improvement in 7 out of 9 attributes. At baseline, 55% of subjects felt their eczema
symptoms had a moderate to extreme impact on overall DLQI score, and 32% were
in the very large to extreme range. After 4 weeks of using the skin care regimen, the
DLQI score was significantly reduced to 6% and 3% in the moderate to extreme and
very large to extreme ranges, respectively. The results provide quantitative evidence
of the positive impact to QOL factors in eczema sufferers, using a mild cleanser and
lotion.
Sponsored 100% by Johnson & Johnson Consumer Companies, Inc.
Sponsored 100% by Unilever R&D.
Oat (Avena sativa) oil activates the PPAR? and PPARb/d pathways,
resulting in keratinocyte differentiation and upregulation of ceramide
synthesis
Michael Southall, PhD, Johnson & Johnson Consumer Companies, Inc, Skillman,
NJ, United States; Apostolos Pappas, PhD, Johnson & Johnson Consumer
Companies, Inc, Skillman, NJ, United States; Chon Suhyoun, Johnson &
Johnson Consumer Companies, Inc, Skillman, NJ, United States; Ruth Earland,
Johnson & Johnson Consumer Companies, Inc, Skillman, NJ, United States
AB64
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
P8355
P8629
Reducing ashiness in skin of color: The impact of mild cleansing
Stacy Hawkins, PhD, Unilever R&D, Trumbull, CT, United States; K. P.
Ananthapadmanabhan, PhD, Unilever R&D, Trumbull, CT, United States; Li
Feng, PhD, Unilever R&D, Trumbull, CT, United States
In skin of color subjects, maintenance of a healthy skin barrier and reduction of skin
dryness is especially important as very dry skin can lead to a gray or ‘‘ashy’’
appearance. It was therefore of interest to investigate the effects of a mild,
moisturizing syndet bar in skin of color subjects with dry, ashy skin, because the
protection benefits may be particularly relevant for this group. Twenty-seven
healthy female subjects, Fitzpatrick type IV-VI, age 20-50 years, with a moderate
degree of visual skin ashiness, as assessed by a dermatologist, provided informed
consent to participate in this IRB-approved home-use cleansing study, where
subjects replaced their normal cleanser with the syndet bar provided and washed
daily for 3 weeks of product application. During this time, subjects refrained from
using moisturizers on their arms or legs. Expert clinical evaluation of dryness and
ashiness and self-perception assessments on forearms and legs were obtained at
baseline and after 3 weeks of product application. Transepidermal water loss
(TEWL) and skin hydration measurements were obtained on forearms and legs at
baseline and at week 3 as an objective measure of skin barrier. Clinical visual dryness
significantly improved on outer forearms and elbows after 3 weeks of normal use
washing. The severity of clinical skin ashiness was also significantly reduced on
outer legs. TEWL and hydration measurements showed significant improvement.
Subjects perceived significant improvement to moisturization, softness, and
smoothness, as well as reduced itch, and dryness on elbows. These results
demonstrate a mild, moisturizing syndet bar provides skin condition benefits in
barrier-compromised, ashy skin.
Safety, pharmacokinetics, and efficacy of AN2728 ointment, 2% in a phase
II study of adolescents with mild to moderate atopic dermatitis
Wynnis Tom, Rady Children’s Hospital, San Diego, CA, United States; Lee Zane,
MD, Anacor Pharmaceuticals, Inc, Palo Alto, CA, United States; Liang Liu, PhD,
Anacor Pharmaceuticals, Inc, Palo Alto, CA, United States; Merrie Van Syoc,
Anacor Pharmaceuticals, Inc, Palo Alto, CA, United States; Sanjay Chanda, PhD,
Anacor Pharmaceuticals, Inc, Palo Alto, CA, United States
Purpose: To evaluate the safety, tolerability, efficacy, and systemic exposure of
AN2728 topical ointment, 2%, in subjects with atopic dermatitis (AD).
Sponsored 100% by Unilever R&D.
Methods: Multicenter, phase II, open-label study with a PK phase (Days 1-9) and a
safety and tolerability phase (Days 10-28). Twenty-three adolescents, ages 12 to 17
years, with mild to moderate AD involving 10-35% body surface area (BSA) were
treated twice daily (BID) with AN2728 ointment, 2% for 28 days, except on Days 1
and 8 when only an AM dose was applied. Plasma samples for PK analysis were
collected on Days 1 and 8 predose and at 1, 2, 4, 6, 8, and 24 hours postdosing, as
well as on Days 4 and 6 before the AM dose. Global assessment of disease severity
was based on the Investigator Static Global Assessment (ISGA), a 5-point scale from
0 (clear) to 4 (severe). Erythema, excoriation, exudation, lichenification, and
pruritus were graded on a 4-point scale from 0 (none) to 3 (severe).
Results: AN2728 ointment, 2% was found to be generally safe and well-tolerated with
the most common adverse events (AEs) being application site reactions. No serious
AEs were observed. One subject discontinued because of an AE (contact dermatitis).
Plasma levels of AN2728 were low and dependent on the BSA being treated. Disease
severity improved over the 28-day treatment period as demonstrated in several
outcomes: mean ISGA score decreased by 1.08 points from baseline; 73.9% of
subjects achieved an ISGA score of 0 (clear) or 1 (almost clear); and treatment
success, defined as an ISGA score of ¼ 1 with a minimum 2-grade improvement from
baseline, was achieved in 34.8% of subjects. Mean values for the individual signs and
symptoms of AD improved during treatment, most notably a 70% reduction in mean
pruritus severity score.
Conclusion: AN2728 is a boron-based phosphodiesterase-4 inhibitor that is wellsuited for the topical treatment of inflammatory skin disorders. Based on these
phase II results in adolescents with AD, AN2728 ointment, 2% applied BID for 4
weeks was generally safe and well-tolerated, provided low systemic exposure, and
produced substantial improvements in global disease severity as well as in individual
signs and symptoms of AD.
Sponsored 100% by Anacor Pharmaceuticals, Inc.
P8672
Safety and efficacy of AN2728 topical ointment, 2% and 0.5%, in a phase II
dose-ranging study of adolescents with mild to moderate atopic dermatitis
Linda Stein-Gold, MD, Henry Ford Hospital, Detroit, MI, United States; Lee Zane,
MD, Anacor Pharmaceuticals, Inc, Palo Alto, CA, United States; Lynda Spelman,
MBBS, Queensland Institute of Dermatology, Holland Park, Australia; Mary
Spellman, MD, Spellman Consulting, San Francisco, CA, United States; Matilda
Hughes, Anacor Pharmaceuticals, Inc, Palo Alto, CA, United States
Purpose: AN2728 is a novel oxaborole compound and phosphodiesterase-4 inhibitor with antiinflammatory activity. A clinical dose-ranging study was conducted to
determine the safety and efficacy of AN2728 topical ointment, 2% and 0.5%,
administered once a day (QD) or twice a day (BID), in the treatment of mild to
moderate atopic dermatitis (AD) in adolescents.
P8580
Results: AN2728 topical ointment, 2% and 0.5%, were found to be generally safe and
well-tolerated. No serious adverse events (AEs) were reported, and no treatment
discontinuation occurred due to AEs. Application site symptoms were uncommon.
Based on improved ADSI scores relative to baseline, a clear dose-response was seen
across the 4 dosing regimens. The greatest improvement in ADSI score was noted
with treatment with AN2728 topical ointment, 2% BID, which yielded a 71%
improvement in ADSI score from baseline after 28 days, with 62% of lesions in this
treatment group achieving total or partial clearance. This treatment group also
demonstrated the greatest improvement across all 5 signs and symptoms of AD after
28 days, including a notable 79% reduction in pruritus severity.
Conclusions: Of the 4 dosing regimens examined in this phase II study of
adolescents with AD, AN2728 topical ointment, 2% BID produced the greatest
improvements in disease severity and was generally safe and well tolerated.
The benefits of ultramild cleansing under normal use conditions for
reduction of winter dry skin itch
Stacy Hawkins, PhD, Unilever R&D, Trumbull, CT, United States; Diana Marrero,
Unilever R&D, Trumbull, CT, United States; K. P. Ananthapadmanabhan, PhD,
Unilever R&D, Trumbull, CT, United States; Li Feng, Unilever R&D, Trumbull, CT,
United States
Damage to stratum corneum proteins and lipids induced by harsh cleansers and/or
severe environmental conditions may also lead to the perception of itch. Previously,
a novel lipid-rich moisturizing body wash (LBW) demonstrated significant clinical
benefits for reducing dryness and improvement of self-perceived skin moisturization. The goal of this research was to understand the impact of ultramild cleansing
on subjective perception of winter dry skin itch. Thirty-four white females, ages 18
to 65 years, provided informed consent to participate in this randomized, doubleblind, IRB-approved 3-week controlled application leg wash study. Subjects were
enrolled into 2 skin condition groups: cell 1—subjects with moderate to severe
clinical visual dryness on their lower legs and self-reported itch (at least 2 itch
episodes 48 hours before the study; N ¼ 18), and cell 2—subjects with none to low
clinical visual dryness and no self-reported itch on their lower legs (N ¼ 16). Each leg
was washed with either the LBW or NMW once daily for 3 weeks during severe
winter conditions (in Connecticut). Clinical evaluation of skin dryness, skin
hydration, and subjective surveys were obtained at baseline, and after 1 and 3
weeks of application. The LBW wash led to a significant reduction in visual dryness,
improved skin hydration, and reduction in perception of itch compared to the NMW
in both low and dry itchy skin subject groups. In addition, the LBW wash showed a
time-dependent reduction in perception of the number of itch episodes and the
intensity of itch. These results demonstrate that the LBW technology is not only
effective for reducing signs of clinical dryness, but also for reducing the symptoms of
itch typically associated with dry winter skin.
Sponsored 100% by Anacor Pharmaceuticals, Inc.
Sponsored 100% by Unilever R&D.
Methods: This multicenter, randomized, double-blind, bilateral, dose-ranging, phase
II study enrolled 86 patients (40% male) aged 12-17 years with AD involving up to
35% of body surface area. Enrolled patients had 2 target lesions of similar severity
based on AD severity index (ADSI) score of 6-12, a maximum 1 point difference in
ADSI score between the 2 lesions, and an erythema subscore of at least 2 (moderate).
The index comprises the sum of scores ranging from 0 (none) to 3 (severe) for
erythema, pruritus, exudation, excoriation, and lichenification. Patients were
randomized to QD or BID treatment frequency. In addition, patients treated 1 target
lesion with AN2728 topical ointment, 2% and the other with AN2728 topical
ointment, 0.5%, and the selection was randomly assigned. Patients were evaluated
on days 1, 8, 15, 22, and 29. Disease severity was determined based on the ADSI
score on days 8, 15, 22, and 29. The primary endpoint was the change from baseline
in ADSI score.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
AB65
P8736
P8337
The impact of severe atopic dermatitis: Analysis of comorbidities
Up-regulation of epidermal differentiation markers filaggrin and claudins
in dry skin
Marius-Anton Ionescu, MD, PhD, Saint-Louis Hospital, Dermatology, Paris,
France; Francine Joly, PhD, Laboratoire Sephrapharma, Puteaux, France; Luc
Lefeuvre, PharmD, Laboratoires Dermatologiques d Uriage, Neuilly-sur-Seine,
France
Hala Adil, MD, Saint Louis University, St. Louis, MO, United States; Elaine Siegfried,
MD, Saint Louis University/Cardinal Glennon Pediatric Hospital, St. Louis, MO,
United States; Eric Armbrecht, PhD, Saint Louis University, St. Louis, Missouri, United
States
Background: Atopic dermatitis (AD) is a chronic inflammatory skin condition that
may be associated with significant morbidity, including sleep disturbance, emotional
distress and reduced quality of life. Well-recognized AD comorbidities include
asthma and allergic rhinitis; however, new data suggest other previously unexplored
associations.
Objective: To identify associations between AD severity and various clinical and
socioeconomic comorbidities, to compare comorbidity prevalence between study
population versus standard norms.
Methods: Retrospective chart review of children with AD seen at the Cardinal
Glennon Children’s Hospital Dermatology Clinics in St. Louis, MO, identified by
Immunocaps panel. Disease severity was defined using the 0-9 point
RajkaeLangeland (RL) criteria, with 0 indicating no AD, and 9 indicating severe
skin disease. A 3-group subset analysis was performed for the majority of parameters,
to better assess trending. The groups were defined by the following scores: 4-5, 6-7,
and 8-9.
Results: 72 patients (33 females, 39 males), ages 3-18 were identified by computer
search. AD was mild-moderate in 54% (n ¼ 39), and severe in 45.8% (n ¼ 33), a
cohort with a higher prevalence of severe AD, as well as other allergic conditions,
than other previously published AD cohorts. Nonallergic comorbidities included 8
(15%) with laboratory evidence of primary immunodeficiency, 8 (12% of the
children ¼ age 4) with mental health disease (including depression, anxiety, ADHD
and autism) and 11 (15%) with failure to thrive. A history of bacterial skin infection
was associated with an increasing trend in AD severity. Laboratory evidence of
primary immunodeficiency was significantly associated with AD severity: 0 with RL
4-5, 14% of those with RL 6-7, and 22% with RL 8-9. Vitamin D deficiency was
detected in a large majority of patients, regardless of severity.
Conclusion: Our cohort of children with AD featured a higher prevalence of severe
skin disease as well as asthma and allergic rhinitis. Allergic comorbidities and
laboratory evidence of primary immunodeficiency were highly associated with
disease severity. We did not find an association between AD and failure to thrive or,
unlike previous publications, mental health disease. Comorbidities that were not
associated with disease severity included: sleep disturbance, vitamin D deficiency,
and treatment nonadherence. Insurance type did not differ among groups with
moderate or severe disease.
Background: Epidermal differentiation markers filaggrin and claudins (part of
intercellular tight junctions) decrease in atopic dermatitis and in several skin
conditions associated with dry skin.
Objective: To compare the expression of epidermal differentiation factors filaggrin
and claudins in dry skin ex vivo treated by 2 emulsions.
Methods: Were compared 2 emulsions: emulsion A—an O/W emulsion with distilled
water as continuous aqueous phase; emulsion B—an O/W emulsion with isotonic
thermal water rich in trace elements and minerals (dispersed phases were identical
in the emulsion A and B). Emulsion A or B were applied on human skin explants
(cultured in medium DMEM) that were previously delipidated with ether/acetone
mixture 1:1 (control untreated). After 5 days incubation were assessed the
expressions of filaggrin, claudin-4, and claudin-6 by immunohistochemistry using
antibodies coupled to fluorochromes (Alexa Fluor 488 for filaggrin, claudin-4 and
claudin-6), nuclei were labeled with DAPI (dilution: 1/100) then observed with a
fluorescence optical microscope (Olympus CK 40).
Results: Keratinocytes’ nuclei were similar in all skin explants. Stratum corneum was
altered and filaggrin labeling was discontinuous in delipidated explants. In explants
treated by emulsion A after the delipidation with ether/acetone, filaggrin expression
was poor and discontinuous. In skin explants treated by emulsion B after the
delipidation with ether/acetone, filaggrin was continuous and more expressed
compared to skin treated by emulsion A and to delipidated untreated skin. Claudins4 and 6 expressions were more important in delipidated skin treated by emulsion B
compared to their expression in delipidated skin treated by emulsion A.
Conclusion: In delipidated skin explants treated by 2 different O/W emulsions,
containing same dispersed phase and different continuous aqueous phase (distilled
vs isotonic thermal water) filaggrin and claudins-4/6 expressions were significantly
more important in skin treated by the emulsion formulated with isotonic thermal
water.
Sponsored 100% by Laboratoires Dermatologiques d’Uriage.
Commercial support: None identified.
P8401
P8439
Treatment of atopic dermatitis with a steroid-free acute therapy emollient
cream reduces eczema severity and the frequency, intensity, and impact of
itch on life activities
Teresa M. Weber, PhD, Beiersdorf Inc, Wilton, CT, United States; Alexander
Filbry, PhD, Beiersdorf AG, Hamburg, Germany; Craig Arrowitz, Beiersdorf Inc,
Wilton, CT, United States; Gitta Neufang, PhD, Beiersdorf AG, Hamburg,
Germany; Ulrich Scherdin, PhD, Beiersdorf AG, Hamburg, Germany
Atopic dermatitis (AD) is characterized by skin-irritating manifestations, including
pruritus and xerosis that adversely impact the quality of life of affected individuals.
This study tested the efficacy and tolerability of a novel steroid-free cream containing
oatmeal, ceramide-3, licochalcone A, and menthoxypropanediol, a cooling agent, to
reduce xerosis, pruritus intensity, frequency, and its influence on life quality. Thirtythree male and female subjects, ages 21-61, with mild to moderate AD active lesions
participated in the 2-week study, with twice daily application of the test-product
(TP). Efficacy was assessed by: a published 5-D itch questionnaire; expert grading of
tolerability, improvement in AD symptoms (0-3 scale), and the AD Severity Index
(ADSI, 15-pt scale); and instrumental measurement of skin hydration and TEWL. The
5-D itch questionnaire assessed frequency of itching, intensity, and impact on work,
social activities, and sleep. Significant improvements in all parameters were
observed. Before treatment with the TP 39% of subjects reported itching 6-18
hours daily and 12% experienced itch18-24 hours daily; at week 2 of treatment, 91%
of subjects reported itching \6 hours if at all. Also at the baseline, 76% reported
moderate to severe itch intensity; at week 2, 88% of subjects reported itch was either
mild or not present. In addition, a high percentage of subjects reported occasional to
frequent impact on their work (61%), and social activities (67%) before treatment. At
the 2 week visit, 88% reported that their itch rarely or never affected their work and
social activities. Lastly, before treatment, 60% reported that itching either delayed
sleep or woke them occasionally to frequently; during treatment, 76% reported that
sleep was not affected at all. Based on investigator’s assessments, statistically
significant improvements in erythema, pruritus, excoriation, and lichenification
were observed at week 2 compared to baseline. Pruritus was reduced from 1.89 at
baseline to 0.83 at week 2. There was also significant improvement in the ADSI at
week 2 (2.6) compared to baseline (5.0). After 2 weeks of treatment, skin lesions
showed significant improvements in hydration (15.42 vs. 22.93) and reduced TEWL
(26.79 vs. 21.11). In summary, the TP significantly improved skin hydration, barrier
condition, AD severity, and demonstrated significant reduction in itch intensity,
frequency, and improvements in life quality due to itch.
Supported by Beiersdorf Inc.
AB66
Use of a stratified human keratinocyte model to predict skin irritation in
subjects with sensitive skin
Trisha Bonner, Johnson & Johnson Consumer Companies, Inc, Skillman, NJ,
United States; Angelica Graves, Johnson & Johnson Consumer Companies, Inc,
Skillman, NJ, United States; Anne-Sophie Brillouet, Johnson & Johnson Consumer
Companies, Inc, Skillman, NJ, United States; Lauren Bernhofer, Johnson &
Johnson Consumer Companies, Inc, Skillman, NJ, United States; Lorena
Telofski, Johnson & Johnson Consumer Companies, Inc, Skillman, NJ, United
States
Background: Standard in vitro tests of products developed for application to the skin
are not designed to predict sensory endpoints, such as stinging. Here we present
results of a keratinocyte-based model originally designed for testing ocular products
for predicting perceived skin irritation responses.
Methods: In vitro models included 2 distinct types of 3-dimensional cultures, derived
from human keratinocytes and structured to resemble either corneal tissue or
epidermal tissue (MatTeK Corp, Ashland MA). In both culture types, irritation
potential was estimated based on reduction in cell viability, using a standardized
MTT-based cell viability assay, following exposure of the cells to test formulations for
various time points up to 24 hours. Time to 50% survival (ET50) was calculated. No
irritation potential was scored as ET50[24 hours. In vitro results were correlated to
the findings from 2 in vivo evaluations in human subjects. In the sting test, lactic acid
reactive subjects exposed the face to 758C steam for 5 min before application of test
formulations to the nasolabial folds for 5 min. Subjects graded any reactions
(stinging, itching, or burning) as mild, moderate, or severe. In the in-home use test,
subjects were asked to use the test formulations at home for 2 weeks and the percent
incidence of perceived irritation was reported. Values [10% indicate unacceptable
irritation.
Results: Four prototype skin care formulations (PSCF) were compared in the 2 in
vitro models. The corneal model proved more sensitive (ET50 range,15-20 hours)
than the epidermal model (ET50 [24 hours for 3 PSCF), and was selected to
progress. Three PSCF previously evaluated by human testing and yielding mild to
moderate sting and higher perceived irritation (range, 12-17%) were subsequently
evaluated in vitro using the corneal model. Each PSCF tested yielded an ET50 ¼ 10
hours. An additional 4 PSCF, evaluated in vitro using the corneal model and yielding
an ET50 [24 hours, were subsequently evaluated in the home use test and had no
sting and low perceived irritation (range, 4-7%).
Conclusions: Use of the corneal in vitro model should be considered as a tool to
predict the potential to cause stinging and perceived skin irritation during use. ET50
values[24 hours were consistent with no sting and low human perceived irritation.
ET50 values of 10 hours were associated with greater irritation potential.
Sponsored 100% by Johnson & Johnson Consumer Companies, Inc.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9227_9230_proof 25 February 2014 11:05 am
DERMATITIS, CONTACT, ALLERGIC AND IRRITANT
P7615
A long-lasting allergic patch test reaction to p-phenylenediamine
Naoki Oiso, MD, PhD, Department of Dermatology, Kinki University Faculty of
Medicine, Osaka-Sayama, Japan; Akira Kawada, MD, PhD, Department of
Dermatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan;
Kayoko Matsunaga, MD, PhD, Department of Dermatology, Fujita
Health University School of Medicine, Toyoake, Japan; Shusuke Uchida, MD,
Department of Dermatology, Kinki University Faculty of Medicine,
Osaka-Sayama, Japan
A long-lasting allergic patch test reaction (LLAPTR) is a positive patch test reaction
persisting over 2 weeks after application of the allergen. A flare-up reaction may
develop on the previously affected lesions during patch testing. We reported a case
of allergic contact dermatitis from p-phenylenediamine (PPD) with both a LLAPTR
and a flare-up reaction. A 61-year-old man was referred to us with pruritic eruptions
on the upper back in January 2013. The patient had used a hair dye for 12 years. The
patient had felt recurring pruritic sensation of the scalp after using the hair dye from
several months before. Pruritic eruptions on the scalp and the upper back had
occurred with general fatigue one day after using the hair dye in December 2012.
Topical corticosteroid had been applied, but pruritic eruptions had been persistent
on the back. Physical examination at the initial examination revealed pruritic
erythematous macules on the upper back. The eruptions ceased 2 weeks later with
application of difluprednate 0.05% ointment. Patch testing was performed with the
Japanese patch test series for hair dyes and permanent waves. Readings were done
on D2, D4, D7 and D38. The patient showed a positive reaction to PPD 1% pet. at D4
(+), D7 (+), and D38 (+), showing a LLAPTR. A flare-up of dermatitis on the scalp
was present at D4 and D7. The clinical history indicated that sensitization occurred
previously and that allergic contact dermatitis with widespread skin lesions
developed after repeated elicitation of allergic contact dermatitis. We happened
to confirm the LLAPTR to PPD at D38, when we checked the flared lesion. It has
been suggested that LLAPTRs are not infrequent than suspected, because they are
not anticipated by the clinician. Some allergens such as gold and PPD can cause very
long-lasting reactions, even when the initial reaction was not too strong. We must
inform our patients that a LLAPTR can happen and be accessible enough to read the
reaction again if it occurs.
Commercial support: None identified.
P7812
Aloe vera gel as a culprit of allergic contact dermatitis: A case report
Jack Short, MD, George Washington University, Department of Dermatology,
Washington, DC, United States; Alison Ehrlich, MD, MHS, George Washington
University, Department of Dermatology, Washington, DC, United States; Kerian
Dodds, George Washington University, Department of Dermatology, Washington,
DC, United States
Objective: To exhibit a case of patch test proven allergic contact dermatitis to 99%
aloe vera gel.
Background: Aloe vera (Aloe barbadensis), a member of the Liliaceae family, is a
well-recognized medicinal plant that which has been used for centuries. Despite its
widespread use and increasing prevalence in new products, reports of allergic
reactions are very rare. Most manufactures use only the aloe gel the from leaf
centers, minimizing any exposure to extracts or other plant components which may
cause irritation. An Austrian patch test study of 702 patients to aloe vera gel, aloe oily
leaf extract, and pulverized complete aloe plant observed no patch reactions to any
of the aloe preparations. Case reports of aloe allergy are few in number, with most
occurring [20 years ago.
Case report: A 51-year-old African American woman presented with a 1-year history
of dermatitis on her back, neck, flexor surfaces of the elbow, and groin area. Patient
had been applying baby oil, petroleum jelly, and a 99% aloe vera gel. Patch testing of
the following trays was performed: North American Standard, Cosmetic, Fragrance,
and patient’s personal perfume and aloe vera gel. At 96 hours, patch tests confirmed
allergic sensitivity to aloe vera (+), as well as 4-phenylenediamine (+), disperse blue
(+), diazolidinylurea (+), and fragrance mix II (+). Patient was advised to discontinue
aloe vera applications because this was determined to be the major culprit of her
reaction.
Discussion: While previous studies have demonstrated the components of aloe vera
gel alone are not likely to induce contact sensitization, our case’s pattern of
dermatitis where she applied aloe, as well positive patch testing, confirmed allergic
contact dermatitis to this rarely allergenic product. Sensitization to other Liliaceae
plants, including Tulipa and Allium, is known, but reactions from the topical
application of commercial aloe gel are very rare. There is potential for cross
reactivity with other Liliaceae, specifically Alliums while gardening or cooking, such
as onions and chives.
Conclusion: With the growing popularity of herbal products and the increasing
prevalence of aloe in consumer goods and cosmetics, sensitization to aloe vera
continues to be very low. This case presents a unique reaction to a product that
many patients would have regarded as harmless or not worthy of mentioning to their
physician.
Commercial support: None identified.
P7694
Allergic contact dermatitis from the use of 2-octylcyanoacryalte
Lara Butler, MD, Geisinger Medical Center, Department of Dermatology, Danville,
PA, United States; Christen Mowad, MD, Geisinger Medical Center, Department
of Dermatology, Danville, PA, United States
Background: As the popularity of topical skin adhesives increases in dermatologic
surgery, clinics, and emergency departments, reports of allergic contact dermatitis
(ACD) from 2-octylcyanoacrylate skin adhesive have been increasingly reported in
the past decade. The skin adhesive 2-octylcyanoacrylate has been proposed to be a
well-tolerated, convenient alternative to traditional techniques for closure of
surgical and traumatic wounds. To date, only 3 cases of ACD related to closure of
wounds with this tissue adhesive have been reported. Herein, we present a case of
delayed ACD to 2-octylcyanoacrylate used for superficial wound closure to highlight
the rising allergenic potential of this commonly used skin adhesive.
Case report: A 33-year-old white woman with no known allergies underwent
bilateral medial thighplasties with liposuction for which 2-octylcyanoacrylate was
used for superficial closure along the medial thighs. Two weeks after her procedure
she developed mild erythema along the lines of surgical wound closure associated
with severe pruritus with increased drainage. By postoperative week 6, she had
developed remarkable bright red linear papules and vesicles along the incision lines
on the bilateral medial thighs, outlining exactly where the skin adhesive had been
used (Fig 1, A and B). Delayed type hypersensitivity reaction to prolonged contact
with 2-octylcyanoacrylate was suspected and confirmed by rechallenge epicutaneous patch testing to 2-octylcyanoacrylate (Fig 2, A). No other acrylate allergies
were identified on further patch testing (Fig 2, B).
P8673
Conclusions: Although allergy to 2-octylcyanoacrylate is currently thought to be a
rare event, clinicians and surgeons who use cyanoacrylate tissue adhesives should
be mindful of this potential complication. In addition, prolonged exposure to 2octylcyanoacrylate may cause sensitization and subsequent ACD. To reduce the
chance of developing ACD, we stress the importance to remove any residual
adhesive from the skin if still present after 2 weeks of application. We speculate that
reports of ACD to 2-octylcyanoacrylate will rise in the literature as its popularity
continues to increase in a variety of medical settings. Although skin adhesives
provide a convenient alternative for superficial wound closure, knowledge of this
possible complication and vigilant surveillance will allow for early identification and
effective treatment.
Contact allergy exacerbating primary cutaneous sarcoidosis
Sivanie Vivehanantha, MBBS, Birmingham Skin Centre, Birmingham, United
Kingdom; Donna Thompson, MBBS, Birmingham Skin Centre, Birmingham,
United Kingdom; Shireen Velangi, MBBS, Birmingham Skin Centre, Birmingham,
United Kingdom
Sarcoidosis is a multisystem granulomatous disorder. Cutaneous sarcoidosis typically
manifests as red-brown flat-topped papules and plaques with a predilection for the
face, lips, neck, upper trunk and extremities. Granulomatous, sarcoidal cutaneous
reactions secondary to contact allergy to metals such as cobalt in tattoos are well
recognized, but there are no previous reports of a contact allergy exacerbating
primary cutaneous sarcoidosis. We report a case of a 54-year-old man with cutaneous
sarcoidosis exacerbated by a contact allergy to p-phenylenediamine (PPD) found in
his hair dye and fragrances in his cosmetic products. A diagnosis of cutaneous
sarcoidosis was made 24 years ago on clinical and histologic grounds with no
evidence of systemic involvement. He had been dyeing his hair for 14 years
following which his condition worsened with increased number of sarcoidal
papules affecting mainly his head and neck, but no dermatitis was noted by
physicians or described by the patient. He had a partial response to topical and
intralesional steroids, though in 2011 there was a significant improvement of his
cutaneous sarcoidosis which was felt to coincide with a 6-month period when he
discontinued dyeing his hair. Patch testing was performed to the European standard,
cosmetic, fragrance, hairdressers and steroid series as well as to his own hair dyes.
Patch testing was positive at 96 hours to PPD, fragrance mix 1, cinnamyl alcohol, and
cinnamal. Allergen avoidance advice was given. We believe that his primary
cutaneous sarcoidosis was exacerbated by a sarcoidal reaction secondary to a
contact allergy. This case highlights the need for clinicians to consider a contact
allergy in patients with cutaneous sarcoidosis who have unexplained localised
exacerbations.
Commercial support: None identified.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:12 pm
AB67
P7948
P8311
Diffuse erythrodermic eczematous dermatitis secondary to subcutaneous
insulin treatment
Ashley De La Cerda, MD, Scott and White Department of Dermatology, Temple,
TX, United States
Efficacy and safety of a natural cream-to-powder formulation on
diaper-wearing infants and children
Hemali Gunt, PhD, MS, Burt’s Bees Inc, Durham, NC, United States; Abena Antwi,
Burt’s Bees Inc, Durham, NC, United States; Celeste Lutrario, Burt’s Bees Inc,
Durham, NC, United States; Stanley Levy, MD, Chapel Hill Dermatology, Chapel
Hill, NC, United States
Background: The SC’s function is to reduce water loss, repel water, protect deeper
layers of the skin from injury, and from microbial infections. In infants, this layer of
the skin is much thinner and more easily disrupted. Diaper rash or irritant diaper
dermatitis develops when skin is exposed to prolonged moisture, increased skin pH
caused by urine and feces, and intertriginous occlusion, resulting in breakdown of
the SC. Hence, any treatment that keeps the skin surface dry helps alleviate this
condition. Most common remedies include moisture-absorbing powders, such as
talc, or barrier creams blocking moisture from reaching the skin. A natural skin
barrier cream was developed that keeps the skin dry and provides moisture
protection.
Diabetes mellitus has become a national epidemic, with [26 million Americans
affected. Most patients are managed with subcutaneous insulin replacement therapy
or oral hypoglycemics. There are numerous cutaneous manifestations of the disease
and cutaneous side effects to the medications used to treat it. We report a rare case of
a patient who developed a diffuse, pruritic erythematous scaly eruption 2 months
after beginning subcutaneous insulin therapy with insulin glargine and insulin
lispro. Multiple tissue biopsies were consistent with an eczematous drug eruption.
The dermatitis cleared over weeks with discontinuation of the insulin, only to
reappear with subsequent administration during hospital admissions. Upon review
of the literature, there have been 2 previously reported cases of a delayed type IV
hypersensitivity drug eruption secondary to preservatives found in subcutaneous
insulin. Patch testing to the components in the insulin can confirm the diagnosis. It
is important to consider insulin as a culprit for erythroderma, because it is often
overlooked in patients on numerous medications and there are insulin preparations
available without the possible offending preservatives.
Commercial support: None identified.
Objective: To evaluate the safety and efficacy of a natural cream-to-powder
formulation in diaper wearing infants and children.
Methods: A 4-week use safety and efficacy study was conducted on 53 diaperwearing subjects ranging in ages from 2 months to 3 years. Erythema, dryness, and
edema were evaluate and clinical graded by a pediatrician at baseline and after 4
weeks of product use. In a separate panel of 20 adult females, wetness protection
was evaluated in vivo using dye exclusion method. The test product was applied to
volar forearm, followed by dye application and skin staining evaluation.
Results: The 4-week use safety and efficacy study showed that the natural cream-topowder formulation did not cause any irritation or sensitization on pediatric
subjects. Dye exclusion revealed significant barrier against wetness on adult
forearms.
Conclusion: The natural cream-to-powder formulation was proven to be safe in
pediatric subjects. The dye exclusion method was able to demonstrate the wetness
protection property of the natural cream-to-powder formulation.
Sponsored 100% by Burt’s Bees Inc.
P8496
P8634
Effect of pseudoceramide cream on irritant hand dermatitis in health care
workers
Marty O. Visscher, PhD, Cincinnati Children’s Hospital Medical Center,
Cincinnati, OH, United States; Andrew DiMuzio, Kao, USA InC, Cincinnati, OH,
United States; Jennifer Jones, Cincinnati Children’s Hospital, Cincinnati, OH,
United States; Lisa Adams, Kao Usa Inc, Cincinnati, OH, United States; Ward
Billhimer, MS, Kao USA, INC, Cincinnati, OH, United States
Routine hand hygiene reduces hospital acquired infections. However, repetitive
hand hygiene is a significant factor in the development of irritant contact dermatitis
in health care workers (HCW). Damaged hands have higher bacterial counts and
increased susceptibility for penetration by irritants and microorganisms.
Maintenance of skin integrity is important for patients and workers. The objective
was to determine the effects on hand skin condition of a pseudoceramide test
cream, designed for moisture barrier repair and substantivity, relative to the hospital
provided lotion among intensive care HCWs in a monitored use study. Sixty-three
subjects participated in the randomized controlled parallel group trial. Assignment
of the test cream or hospital lotion was stratified by baseline knuckle dryness scores;
application was 33 daily. The primary outcome was skin condition measured as
expert visual scoring of dryness and erythema, digital imaging and analysis, stratum
corneum integrity (TEWL), and skin hydration (capacitance) after 1, 2, and 4 weeks.
Data were analyzed using linear mixed models with repeated measures. There was
significant irritant dermatitis at baseline as over 60% of HCWs had knuckle dryness
and erythema scores of 2. After 4 weeks, hands treated with the test cream were
significantly less dry and irritated versus the hospital lotion as well as lower dryness
on the knuckles and dorsum of both hands (P \.05) and as lower erythema on the
knuckles of both hands and the left dorsum (P \.05). Skin treated with the test
cream had a more competent stratum corneum barrier, than that of the hospital
lotion group (P \.05) as evidenced by lower TEWL. For the test cream and hospital
lotion, respectively, TEWL values were 26.2 and 21.6 g/m2/hr at baseline and 21.6
and 25.6 g/m2/hr at week 4. Hand skin of the test cream group was more hydrated
than the hospital lotion group, as evidenced by higher Corneometer readings, for
both dorsum and the left hand knuckles (P \.05). Mean daily usages were 4.5 and
4.8 times for test and hospital lotion, respectively. In addition, application of the
highly substantive test cream 4-5 times daily significantly reduced the severity of
irritant contact dermatitis in HCWs. Subjects reported the test cream as protective
and moisturizing, characteristics that likely impact compliance.
Supported by Kao USA, Inc.
AB68
Impact of co/cross-reactants on available alternative hair dyes in
p-phenylenediamine allergic patients
Gurbir Dhadwal, MD, Department of Dermatology and Skin Science, University
of British Columbia, Vancouver, Canada; Gillian de Gannes, MD, Department of
Dermatology and Skin Science, University of British Columbia, Vancouver,
Canada
Background: P-phenylenediamine (PPD) is a common component of permanent and
semipermanent hair dyes. However, it is also a common allergic contact allergen.
Published rates of sensitization to PPD, amongst patients presenting for patch
testing, range between 2% and 12%. Given the rates of sensitization, hair dyes
containing alternatives to PPD have been developed. Here we attempt to determine
if co/cross-reactants found in these alternative hair dyes will limit their use by PPD
allergic patients.
Methods: We retrospectively reviewed all patch test results of patients presenting to
the Vancouver Patch Test Clinic between November 2008 and June 2013. All
patients were tested to the North American Contact Dermatitis Group standard
screening series and other standard sets of allergens as clinically indicated, such as a
hairdressing tray. Data was collected for all positive reactions to PPD and those
results were further analyzed to find all co/cross-reactants. The American Contact
Dermatitis Contact Allergen Management Program (CAMP) database was then
queried with PPD along with each of the most common co/cross reactants for
available hair dyes without those ingredients.
Results: 1319 patch tests were performed during the study period. 95 patients were
found to be patch test positive to PPD. Of those 95 patients, 74 (78%) had at least 1
other positive reaction. The 10 most common co/cross reactants were nickel (31%),
ammonium persulfate (23%), cobalt (ii) chloride hexahydrate (20%), p-toluenediamine sulfate (19%), 4-aminophenol (18%), fragrance mix 1 (15%), toluenediamine
base (12%), fragrance mix 2 (9%), myroxylon pereirae resin (9%) and glyceryl
thioglycolate (9%). The CAMP database contained 180 PPD-free dyes. Nickel, cobalt,
ammonium persulfate, or glycerly thioglycolate were not found to be components of
the PPD-free dyes. Cross-reacting to 4-aminophenol restricted available dyes to 52.
Cross reacting to toluenediamine compounds restricted the available dyes to 19,
none of which were dark in color. Positivity to any of the fragrances restricted the
availability to 1 nonpermanent dye.
Conclusions: Patients who are allergic to PPD are commonly allergic to other
chemicals. Patients that are PPD allergic and also react to toluenediamine or
fragrances are severely restricted in their choice of hair dye. The clinic relevance of
fragrance allergy in patients wishing to dye their hair is unclear and likely warrants
additional investigation.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P8469
P8368
Methyl methacrylateeinduced purpuric contact dermatitis
Lauren Strazzula, Massachusetts General Hospital, Boston, MA, United States;
Daniela Kroshinsky, Massachusetts General Hospital, Boston, MA, United States;
Shinjita Das, Massachusetts General Hospital, Boston, MA, United States; Vinod
Nambudiri, Massachusetts General Hospital, Boston, MA, United States
Peristomal contact dermatitis in cancer patients: Preliminary results
Viswanath Reddy Belum, MD, Memorial Sloan-Kettering Cancer Center, New York,
NY, United States; Jonathan H Zippin, MD, PhD, New York Presbyterian
HospitaleWeill Cornell Medical Center, New York, NY, United States; Mario E
Lacouture, MD, Memorial Sloan-Kettering Cancer Center, New York, NY, United States
A 26-year-old dental student with reported allergies to wool, nickel, and silver
presented to the emergency department with a 1-month history of pain, blistering,
and swelling along the first 3 digits of her left hand. Her symptoms were so severe
that she was forced to reschedule her laboratory practical examination. In the weeks
before her presentation, she had been evaluated by her primary care physician and
at an outside emergency department where she was unsuccessfully treated for
suspected eczema and herpetic whitlow. A detailed contact history revealed that the
patient had been using a new dental resin containing methyl methacrylate while
working with molds of human teeth. On physical examination, she had superficial
desquamation along palmar surface of the first 3 digits of her left hand with a
prominent purpuric patch at the distal tip of her first finger. She was discharged
home on a short course of oral prednisone along with topical steroids and instructed
to avoid methyl methacrylate exposure if possible. Two weeks later, her rash had
markedly improved. Methyl methacrylate is an acrylic monomer that is commonly
found in dental resins and bonding agents, artificial nail adhesives, and glues. A
contact dermatitis to methyl methacrylate may occur in individuals with occupational exposure and can occasionally result in the need to change professions.
Purpuric contact dermatitis is a rare phenomenon that has been reported to occur in
individuals exposed to a variety of agents such as dyes, glues, and rubber materials.
To the authors’ knowledge, a purpuric contact dermatitis to methyl methacrylate
has only been reported in one other patient in the English literature. This case
highlights the importance of a detailed contact allergen history in individuals
presenting with purpura suspicious for a contact dermatitis to reduce unnecessary
diagnostic procedures and potentially harmful treatments.
Background: Peristomal dermatitis is a common condition seen in approximately
two-thirds of ostomy patients. The peristomal skin is continually exposed to a
number of substances, including urine, stool, medications, and stoma bag products,
creams, and adhesive removers. While irritant contact dermatitis is a well-defined
cause of peristomal contact dermatitis, allergic etiologies are less well understood.
Stoma bag products, creams and adhesive removers are being increasingly marketed;
however, the potential cutaneous adverse effects associated with their use has
received little attention. This is of particular importance in cancer patients who
experience wide-ranging adverse events from their chemotherapy and/or surgery.
Commercial support: None identified.
Objectives: To critically evaluate both irritant and allergic etiologies for peristomal
contact dermatitis in the oncology setting.
Methods: This was a retrospective chart review (January 2010 to current) of patients
who had been referred to the dermatology department by their oncologist for
peristomal dermatitis. All patients were treated at the Memorial Sloan-Kettering
Cancer and Weill Cornell Medical Centers. The records and images of patients with a
provisional diagnosis of contact dermatitis were identified and analyzed.
Results: A total of 26 ostomy patients with single/multiple stomas: colostomy (16),
ileostomy (1), ileal conduit (10), or wound vac (1) were identified. The patient ages
ranged from (37-87 yrs) with a male:female ratio of 2:1. The most common diagnoses
were colorectal and bladder cancers. In a majority of patients, erythema in the
vicinity of their stoma appliances, pruritus and soreness were the most common
presenting features. Eight patients were ROAT tested for products used to clean or
care for their ostomies and 50% of them were reactive to these products such as
Durahesive and PDI. Reactions ranged from 1+ to 3+ and were suggestive of an
allergic contact dermatitis. Confirmatory patch testing with individual components
of these products is in progress.
Conclusions: While peristomal irritant contact dermatitis is known to occur after
exposure to urine and stool, possible sources of allergic contact dermatitis are less well
understood. We have identified several new stoma care products as possible allergen
containing products. Because these products are commonly used to treat or prevent
peristomal-related irritant contact dermatitis we feel these products deserve additional
study. These products must be interrogated as potential causes of allergic contact
dermatitis and causative allergens used in their manufacturing should be established.
Commercial support: None identified.
P8611
Recognition and management of recurrent dermatitis following a jellyfish
sting
Lori Asztalos, MD, MS, The Children’s Hospital of Philadelphia, Department of
Dermatology, Philadelphia, PA, United States; Adam Rubin, MD, University of
Pennsylvania Department of Dermatology, Section of Dermatopathology,
Philadelphia, PA, United States; Caroline Groft-MacFarlane, MD, PhD,
Dermatology Associates of Bryn Mawr Medical Specialists, Wynnewood, PA,
United States; Leslie Castelo-Soccio, MD, PhD, The Children’s Hospital of
Philadelphia, Department of Dermatology, Philadelphia, PA, United States;
Rosalie Elenitsas, MD, University of Pennsylvania Department of Dermatology,
Section of Dermatopathology, Philadelphia, PA, United States
Introduction: Jellyfish stings produce an acute eruption at the site of envenomation.
They also may cause a less common recurrent dermal hypersensitivity reaction that
is intensely symptomatic and nonresponsive to antihistamine therapy. Unlike acute
reactions, presenting as painful papules and urticaria, recurrent reactions present
with a variety of skin findings including itchy papules and plaques, localized fat
atrophy, hyperhidrosis that may necessitate a different approach to management.
Cases of recurrent reactions are extremely rarely reported and, in this case of
recurrent reaction, it was successfully treated with topical tacrolimus and intralesional triamcinolone acetonide. No previous reports using intralesional corticosteroids and only 1 report of treatment with topical tacrolimus in the treatment of
recurrent jellyfish envenomation reactions.
P8728
Nickel ions transferred by fingers
Juan Vilaplana, MD, Antonio Puig, Barcelona, Spain; David Isnardo, Antonio Puig,
Barcelona, Spain; David Panyella, PhD, Antonio Puig, Barcelona, Spain; Jordi
Vidal, Antonio Puig, Barcelona, Spain
Introduction: We are used to visit patients with suspected allergy to cosmetics that at
the end, an only positive reaction to nickel is found after a patch test. In order to
know if this metal can be transferred by fingers we have performed the next study.
Methods: Adhesive tape is used to collect nickel from volunteer hands after being in
contact with coins. A stripping process was performed several times over palmar
skin until obtaining 2 grams of tape. The previous methodology was repeated with a
group of volunteers who were not in contact with coins. As a control blank, 2 grams
of tape was measured to know the nickel concentration. Microwave digestion
technique is used to dissolve heavy metals before analysis by inductively coupled
plasma.
Case report: A 9-year-old girl presented with pruritic papules on the left lower leg,
One year earlier, she was stung by a jellyfish and developed an acute reaction that
was self-treated with baking soda and vinegar. One week after resolution, she
developed an itchy red rash at the site mildly improved with topical corticosteroids.
A skin biopsy was performed and histology showed a superficial and deep dermal
infiltrate composed of lymphocytes and many eosinophils with degranulation and
early flame-figure formation. PAS and AFB stains did not show presence of
organisms. Skin tissue cultures did not show atypical myocbacteria or fungus.
Initially, the patient started daily oral cetirizine and topical desoximetasone
ointment twice daily for 3 wks followed by tacrolimus ointment once daily for 3
weeks. The dermatitis and pruritus improved but recurred each time she stopped
treatment. After 4 months of waxing and waning, the patient received triamcinolone
acetonide injections and the rash no longer recurred.
Methods: A systematic review of literature was performed in 2013 using Medline
searching for key words of recurrent dermatitis and jellyfish envenomation.
Results: An statistical increase in nickel concentration is observed when a volunteer
has been in contact with coins. In the other hand, the nickel concentration detected
in the other volunteers group was significantly lower.
Conclusions: Based on the results, the nickel transferred by fingers could explain the
patch test results.
Discussion: This case illustrates the importance of recognizing recurrent envenomation reactions induced by jellyfish stings and the potential benefit of using agents,
such as topical tacrolimus and/or intralesional corticosteroid injections for
treatment. Immunomodulators lead to positive treatment response most likely
because of an immunologic mechanism associated with elevated antijellyfish
immunoglobulins or intracutaneously sequestered antigen.
Commercial support: None identified.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
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AB69
P8146
P7779
Relevance of plant series of allergens (Chemotechnique Diagnostics) in
north Indian patients with suspected occupational contact dermatitis to
plants
Dipankar De, MD, Postgraduate Institute of Medical Education and Research,
Chandigarh, India; Sanjeev Handa, MD, Postgraduate Institute of Medical
Education and Research, Chandigarh, India
Background: There are 5000 representatives of sesqueterpene lactones, one of the
commonest groups of allergens responsible for plant induced contact dermatitis
worldwide. Parthenium and xanthium together, both containing sesqueterpene
lactones as allergenic moiety, is the cause of positive patch test reactions in almost
40% of patch tested patients in India where majority of contact dermatitis clinic
attendees are farmers or individuals involved in farming as a part-time job. Ironically,
only 1 allergen represents the plants in the Indian Standard Series of allergens for
patch testing, namely parthenolide, supplied presently either by CREDISOL or
Chemotechnique Diagnostics.
Telangiectatic reticular erythema
Carmen Diaz-Sarrıo, MD, Consorci Sanitari del Garraf, vilanov i la Geltru, Spain;
Miguel Vi~
nas-Arenas, MD, Consorci Sanitari del Garraf, Sant Pere de Ribes, Spain;
Victor Fumanal-Orus, Consorci Laboratori Intercomarcal Alt Penedes, Anoia i
Garraf, Sant Pere de Ribes, Spain; Xavier Garcia-Navarro, MD, Consorci Sanitari
del Garraf, Sant Pere de Ribes, Spain
Objective: To assess whether plant series of allergens supplied by Chemotechnique
Diagnostics helps in confirmation of suspected contact dermatitis to plant allergens
in North Indian patients so that relevant allergens in our context be included in the
standard series of allergens or the plant series be used in a particular set of patients.
Methods: Nonatopic patients attending our contact dermatitis clinic with hand
eczema, eczema on exposed extremities and/or face, air-borne contact dermatitis
pattern whose predominant occupation was handling plants or plant products like
agriculturist, horticulturist, florist, gardeners, cattle handlers, etc were studied.
Patches of 14 allergens supplied by Chemotechnique Diagnostics were applied and
read at 48 and 96 hours according to ICDRG criteria.
Results: Of the 37 patients tested with the plant series (Chemotechnique
Diagnostics), 32.4% were positive to parthenolide, 19% to SQL mix, 5.4% each to
alantolactone and tenacetum vulgare, and 2.7% each to chrysanthemum, diallyl
disulphide, lichen acid mix, and achillea millefolium. When we compared the results
with indigenously developed extracts of local plants (but not commercially
available) applied to 27 patients of suspected contact dermatitis to plant allergens
before initiating this study, 70.4% were positive to parthenium extract, 44.4% to
compositae mix, 29.7% to parthenolide, and 18.5% were positive to all 3 allergens.
Conclusions: Parthenolide individually and plant series by Chemotechnique
Diagnostics collectively are not good agents to detect plant contact dermatitis in
Indian patients. Because allergen content may vary in different geographic areas,
even for a particular species of plant, it is imperative that plant allergen series be
made from locally grown and locally relevant plants.
Background: Reticular telangiectatic erythema (RTE) is a recently described skin
complication. In the last few years, cutaneous complications after implantation of
medical devices have been increasingly reported as a result of the more widespread
use of such devices. Remarkable histologic findings include telangiectasia and
interstitial lymphohistiocytic infiltrate.
Case report: We present a patient with erythematous lineal nonpruriginous plates
on the anterior side of the upper left hemithorax and the left shoulder. The patient
had undergone surgery with metal anchors and rotator cuff reinsertion. Histologic
findings showed marked ectasia of dermal capillaries, perivascular lymphohistiocytary infiltrate, and mild focal spongiosis.
Conclusions: Most described RTE cases are associated with cardiac pacemakers,
cardioverter defibrillators, morphine pumps or spinal cord stimulators. Differential
diagnosis should be made against contact dermatitis, reactive angioendotheliomatosis and reticular erythematous mucinosis. RTE is most often a diagnosis of
exclusion, supported primarily by the temporal relationship with device implantation, negative patch test results, and the absence of infection signs.
Commercial support: None identified.
Commercial support: None identified.
P8454
Conclusions: Prevalence of contact sensitization appears to have not changed much
during the decade. Additional research involving patients from all institutions in
Bangkok, would provide a more comprehensive view of contact allergens in the
region and lead to generate our local standard series.
The beak sign: A clinical clue to airborne contact dermatitis
A. Nichole Sullivan, Indiana University School of Medicine, Indianapolis, IN,
United States; Michael P. Sheehan, MD, Department of Dermatology Indiana
University School of Medicine, Indianapolis, IN, United States; Navid Ezra, MD,
Department of Dermatology Indiana University School of Medicine, Indianapolis,
IN, United States; Nico Mousdicas, MBChB, MD, Department of Dermatology
Indiana University School of Medicine, Indianapolis, IN, United States
Importance: Approximately 1 in 5 persons in North America and Western Europe
suffer from some form of contact dermatitis. Airborne contact dermatitis (ACD) can
result from exposure to allergen or irritant-inducing materials that have potential for
transmission as dust, droplets, or gas. Major causes of ACD include metals, organic
compounds, chemical solvents, pesticides, and plant-derived substances (eg,
tobacco smoke and fragrances). ACD can at times present a difficult clinical
diagnostic challenge. We present a new clinical sign to aid in diagnosis and
management.
Observations: We report 3 cases of ACD that present with sparing of the skin of the
nose, a finding that we have termed the ‘‘beak sign.’’ The unique distribution of the
presenting dermatosis facilitates the diagnosis, and a detailed history of possible
exposures may lead to identification of the responsible contactants. In these
patients, we determined the diagnosis of ACD by our clinical observation, the
patient’s history, and, in some cases, by closed patch testing. All patients
demonstrated variable dermatitis distribution, yet consistently showed sparing of
the nasal skin. We wish to highlight this ‘‘beak sign’’ as a consideration in the
diagnosis of airborne contact dermatitis.
Conclusions: In the appropriate clinical setting (eg, concordant patient history,
known exposures, and positive skin-patch testing), the ‘‘beak sign’’ may facilitate a
diagnosis and, thus, the clinician’s ability to counsel the patient to avoid continued
exposure to the offending agent. In our experience, this sign represents the ‘‘face of
airborne contact dermatitis,’’ because it strikingly presents when encountering such
patients at initial consultation and therefore offers an instantly recognizable clinical
clue in the diagnosis of ACD. Clinicians encountering patients with variable
dermatitis of the head and neck with sparing of the nasal skin should perform
thorough histories investigating exposures to aerosolized contactants, including but
not limited to perfumes, pollens, and tobacco smoke. Identification by history alone
may quickly lead to the source and elimination of the offending agent, possibly
reducing the need for blood tests and closed patch testing.
Commercial support: None identified.
Commercial support: None identified.
P7558
Risk factors of common contact allergens and trends of patch test results
to a modified European baseline series in Thais during the 2000s
Waranya Boonchai, MD, MMSc, Department of Dermatology, Faculty of Medicine
Siriraj Hospital, Mahidol University, Bangkok, Thailand; Pacharee Iamtharachai,
Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand
Background: Surveillance of contact allergy of patch-tested patients has demonstrated its value in detecting time trends. This study aims to identify trends of
positive reactions in patients patch tested at contact dermatitis clinic, Siriraj
Hospital, Bangkok since 2000 and risk factors for common allergens.
Methods: A retrospective review of medical records was conducted from January
2000 to December 2009. All patients who patch tested with our standard series were
studied.
Results: There were 852 cases (206 males and 646 females; mean age 39.14 years).
The top 5 most frequent allergens were gold sodium thiosulfate (30.7%), nickel
sulfate (27.6%), potassium dichromate (20.8%), fragrance mix (18.3%), and cobalt
chloride (16.0%), respectively. Gold sensitivity was found more common in female
and at head and neck regions. Nickel sensitivity was more common in women.
Chromate sensitivity was more common in male and at ages of ¼ 40 years. Fragrance
sensitivity was more common in female and at ages of ¼ 40 years.
AB70
J AM ACAD DERMATOL
MAY 2014
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P7533
P7555
Trends in patch test results and allergen changes in the standard series: A
Mayo Clinic 5-year retrospective review (January 1, 2006 - December 31,
2010)
Ashley Wentworth, Mayo Medical School, College of Medicine, Rochester, MN,
United States
Background: Patch testing is essential for identification of the culprit causing allergic
contact dermatitis. We previously examined our 10-year experience with a dynamic
standard series of allergens in 2 reports (1996-2000; 2001-2005).
Objective: To identify trends and allergen changes in our standard series during
2006-2010, compared to our previous report (2001-2005) and the 2005-2006 results
published by the North American Contact Dermatitis Group.
Unilateral eruptions on the face: Consider cellular phone contact
dermatitis
Jeannette Olazagasti, University of Puerto Rico, School of Medicine, San Juan, PR;
Deon Wolpowitz, MD, PhD, Department of Dermatology, Section of
Dermatopathology, Boston University School of Medicine, Boston, MA, United
States; Yoon-Soo Cindy Bae-Harboe, MD, Department of Dermatology, Boston
University School of Medicine, Boston, MA, United States
As technology continues to spread around the world, ever more cases of nickel
allergy caused by cell phone usage are seen. ACD occurs when the immune system
reacts against an allergen, in this case nickel, and nickel allergy today remains the
most frequent contact allergy worldwide. Most cases of allergic contact dermatitis
may be diagnosed from taking a thorough medical history and completing a physical
examination. However, if the cause of the contact dermatitis remains unclear, patch
testing may be performed. If a patient is tested positive for nickel, he or she will be
advised to avoid nickel materials as much as possible. Interestingly, nickel is found in
items such as keys or coins, which people interact with on an everyday basis;
nevertheless, the sensitization to nickel does not develop as easily because contact is
usually brief. Cases of nickel allergy are therefore more commonly seen with items
used for prolonged periods of time, such as earrings, necklaces, watches, and buckle
belts. Because many cell phone companies now allow plans with unlimited minutes,
the resulting increased time of use will likely make cell phones another major cause
of nickel allergy. Avoidance strategies for cell phone nickel allergies include plastic
covers, hands-free ear pieces, or tested nickel-free cell phones. We present a case of
a 48-year-old African American woman with a unilateral left preauricular lichenified,
pruritic plaque. Further questioning revealed this to correspond exactly to where
her smartphone contacted her face. Subsequent 3+ positive patch test to nickel and
complete resolution of the rash after switching to a hands-free ear piece confirmed
the diagnosis of cell phoneeinduced allergic contact dermatitis. With only a handful
of previous reports in the literature, we believe that these cases are underreported.
Moreover, as smart phone usage increases, more such cases will be encountered in
routine clinical practice. This case therefore highlights the importance of
considering allergic contact dermatitis in the differential diagnosis of unilateral
eruptions on the face.
Design: Retrospective review of patch test results obtained using a standardized
technique and enabled by an electronic database.
Results: Three thousand one hundred fifteen patients were tested with a mean of
73.0 allergens. Two-thirds of these patients had at least 1 positive allergic reaction.
The most common reaction-causing allergens were gold sodium thiosulfate, 2%
formulation; nickel sulfate hexahydrate, 2.5%; and Myroxylon pereirae resin
(balsam of Peru), 25%. A large proportion of final patch test readings for many
allergens were categorized as mild reactions (erythema only). There was a significant decrease (P ¼.006) in the overall rate of positive allergic reaction (66.0%) to at
least 1 allergen as compared to 2001-2005 (69.1%). The rate of irritant patch test
results also declined significantly (P \.001), from 25.0% in 2001-2005 to 14.3% in
2006-2010. Since our previous report, 8 allergens were added to the standard series;
14 were deleted. Significantly higher rates of allergic positive reaction were
documented for carba mix (3%) and disperse orange 3 (1%). Rates were lower for
10 allergens: neomycin sulfate (20%); gold sodium thiosulfate (0.5%); hexahydro1,3,5-tris(2-hydroxyethyl)triazine (1%); disperse blue 124 (1%); disperse blue 106
(1%); diazolidinyl urea (1%); hexylresorcinol (0.25%); diazolidinyl urea (1% aq);
2-bromo-2-nitropropane-1,3-diol (0.25%); and lidocaine (5%). The 3 Mayo Clinic sites
differed in individual allergen reaction rates. The rate of positive allergic reaction to
at least 1 allergen (66.0%) was not significantly different (P ¼.52) from that reported
by the North American Contact Dermatitis Group (65.3%).
Limitations: Retrospective study and lack of long-term follow-up.
Conclusions: Presentation and interpretation of patch test results provide clinically
useful information regarding trends in allergenicity, informing adjustments to the
standard series. Since our previous report, our standard series composition has
changed, and the overall rates of allergenicity and irritancy have decreased. Notably,
many final patch test readings showed mild reactions.
Commercial support: None identified.
Commercial support: None identified.
DERMATOPATHOLOGY
P8467
P8076
Type IV hypersensitivity reaction from enoxaparin
Rachel Anolik, MD, Boston University School of Medicine Department of
Dermatology, Boston, MA, United States; Debjani Sahni, MD, Boston University
School of Medicine Department of Dermatology, Boston, MA, United States; Jag
Bhawan, MD, Boston University School of Medicine Department of Dermatology,
Boston, MA, United States; Yoon-Soo Cindy Bae-Harboe, MD, Laser and Skin
Surgery Center of New York, New York, NY, United States
Heparins and heparinoids are a rare but documented cause of type IV cutaneous
hypersensitivity reactions. Diagnosis is critical because patients are frequently on
chronic anticoagulation and reactions can progress to systemic involvement. A 63year-old man presented with pruritic lesions on the abdomen for 3 months.
According to the patient, the lesions appeared 1-2 days after subcutaneous
enoxaparin injections in his abdomen. The patient had taken dalteparin about 1.5
years before presentation without consequence. His medical history was significant
for a stroke, hypertension, hyperlipidemia, atrial fibrillation, and obesity. His
medications included hydrochlorothiazide, atenolol, amlodipine, and enoxaparin.
The physical examination revealed 2 well-demarcated round pink thin plaques with
a dusky center and minimal scale. Punch biopsy of one of the lesions showed
parakeratosis, scale crust with neutrophils, focal hypogranulosis, epidermal hyperplasia, mild spongiosis with lymphocytic exocytosis, a mild superficial perivascular
lymphocytic infiltrate with eosinophils and neutrophils, and minimal dermal mucin.
Given the clinical and pathologic findings, a diagnosis of drug-induced type IV
hypersensitivity spongiotic dermatitis was made. Type IV hypersensitivity reactions
to heparins, including unfractionated and low molecular weighteheparins, are a
rare but documented entity. These reactions are underreported, because they
usually present as eczematous lesions on the abdomen, which may be misattributed
to other etiologies. Diagnosis can be confirmed by skin testing, which is useful for
determining the cross reaction potential between the various heparins and
heparinoids. Correct identification of the allergen and determination of potential
cross reactants is crucial to prevent additional allergic skin reactions and preventing
more serious systemic reactions, including anaphylaxis, which has been reported
after administering intravenous heparin in the setting of subcutaneous enoxaparin
sensitization. Many patients on anticoagulation require chronic or lifelong therapy
so determination of an appropriate medication is necessary with a flexible
individualized approach. After stopping enoxaparin and starting triamcinolone
0.1% ointment, our patient’s rash resolved within a week. Skin testing may be
helpful in his case if additional anticoagulation with a heparin or heparinoid is
necessary for future treatment.
A case of angioinvasive lymphomatoid papulosis type E
Julia Kreger, University of New Mexico, Albuquerque, NM, United States; Barrett
Zlotoff, MD, University of New Mexico, Albuquerque, NM, United States; Laura
Keck, MD, University of New Mexico, Albuquerque, NM, United States; Shelly
Stepenaskie, MD, University of New Mexico, Albuquerque, NM, United States
Commercial support: None identified.
Background: Lymphomatoid papulosis (LyP) is a rare, papulonodular skin disorder
that is classified as part of a group of cutaneous CD30+ lymphoproliferative
disorders. LyP shares histologic features with CD30+ malignant anaplastic large
cell lymphoma and may increase the risk for developing a secondary lymphoid
malignancy. Historically, there have been 4 types of LyP based on histology. Recently,
a fifth type of LyP, type E, was described by Kempf et al: angioinvasive LyP. It is
characterized by ulcerative papules with angiocentric infiltrates of CD30+ lymphocytes. We add a case of this rare variant of LyP to the growing literature.
Case report: We present a case of a 25-year-old man with a 6-month history of
generalized pruritus. He was incarcerated with a history of intravenous drug use and
hepatitis C. Cutaneous examination was significant for well-demarcated, erythematous and violaceous papules with scale in a generalized distribution. There were
hemorrhagic, necrotic papules on the lower extremities in various stages of healing.
Differential diagnosis included pityriasis lichenoides et varioliformis acute (PLEVA),
a leukocytoclastic vasculitis, LyP, and arthropod assault. A skin biopsy revealed
dermal aggregates of CD30+ cells and a lymphohistiocytic infiltrate that surrounds
and focally infiltrates the superficial and deep vessels. The diagnosis of angiocentric
CD30+ lymphoproliferative disorder, lymphomatoid papulosis (LyP), type E, was
made. The cutaneous eruption regressed with the use of systemic steroid treatment,
but he experienced relapse when attempts were made to decrease the dosage of
systemic steroids.
Discussion: This case describes the clinicopathologic findings of a rare variant of LyP.
The rapid development of hemorrhagic and necrotic ulcers and histologic findings
of angiocentric CD30+ lymphocytes make this disorder difficult to differentiate from
an aggressive lymphoma. There are very few case reports in the literature. The
majority of ulcerations demonstrate spontaneous regression after 3 to 6 weeks.
Persistent lesions in the literature have shown a positive response to UV light
therapy and methotrexate. Secondary lymphoid neoplasms have not been reported
in the setting of angioinvasive LyP. Recurrences of type E LyP have been reported,
but the prognosis to date is excellent. Despite its similar histopathology, LyP type E
has markedly different prognoses and treatment plans reinforcing the importance of
the diagnosis.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB71
P7855
P8025
A mixed picture: Cellular angiofibroma and pleomorphic liposarcoma
Kristyn Beck, MD, Eastern Virginia Medical School, Norfolk, VA, United States;
Joan Paul, MD, MPH, Dartmouth Hitchcock Medical Center, Lebanon, NH, United
States; Robert Pariser, MD, Virginia Clinical Research, Norfolk, VA, United States
Anti-CD117 in sweat gland tumors
Stephanie Frisch, MD, Saint Louis University Department of Dermatology, Saint
Louis, MO, United States; Claudia Vidal, MD, PhD, Saint Louis University, Saint
Louis, MO, United States; Eric Armbrecht, PhD, Saint Louis University, Saint
Louis, MO, United States; Nicole Burkemper, MD, Saint Louis University
Department of Dermatology, Saint Louis, Missouri, United States
Cellular angiofibromas are a recently described subtype of benign spindle cell
tumors. They are equally prevalent in both males and females and are most often
located in the subcutaneous tissue of the inguinoscrotal or vulvovaginal region.
Middle-aged individuals are most commonly affected. Although cellular angiofibromas are reported to have an equal sex incidence, males often present with larger
lesions. The clinical presentation is that of a painless mass measuring between 0.5
and 25 cm, which rarely recurs after excision. The histopathology is characterized
by a bland spindle cell component with short bundles of wispy collagen intermixed
with thick-walled, often hyalinized vessels. Twenty percent of cellular angiofibromas contain some component of intralesional fat, but significant cellular atypia
and/or mitoses are rarely reported. Immunohistochemical staining of cellular
angiofibromas is often positive for vimentin. Sixty percent of cases stain positive
for CD34, while only 20% stain positive for smooth muscle actin. However, none
have been reported to express either S100 or caldesmon. Although this tumor often
follows a benign course without recurrence, cellular angiofibromas have rarely been
reported to have a malignant course characterized by sarcomatous transformation.
Histologically, an abrupt transition is often seen between areas of benign stromal
tumor and malignant sarcomatous tumor. The most commonly reported malignant
transformations are atypical lipomatous tumor, pleomorphic liposarcoma and
pleomorphic sarcoma not otherwise specified (NOS). Although the exact mechanism of transformation is not completely understood, the overexpression of p16 in
areas of malignant transformation implicates a possible molecular role in the
pathogenesis. Fortunately, there is little evidence to support an increased likelihood
for local recurrence or metastasis in this subgroup of patients. However, recognition
of this clinical entity is essential for early detection and effective treatment of this
rare and therefore diagnostically challenging neoplasm.
Background: Previous immunohistochemical staining with anti-CD117 has shown
expression in basal keratinoyctes, mast cells, melanocytes, and sebaceous and sweat
glands. Anti-cKIT expression in specific sweat gland tumors has not been elucidated.
Methods: 10 samples of normal skin were stained with anti-cKIT. 10 samples of
poroma, hidradenoma, spiradenoma, syringoma and cylindromas were also stained
with anti-cKIT. Percentages of ductal and epithelial staining and intensity of staining
were recorded.
Results: CD117 highlights the epithelium of eccrine tumors of secretory coil and
acrosyringium origin that is statistically significant. Spiradenoma and hidradenoma
exhibit greatest percentage of epithelial staining with strong and moderate-strong
intensity. Cylindromas, hidradenomas, and spiradenoma exhibit greatest percentage
of ductal staining with strong intensity.
Conclusion: Normal skin anti-CD117 staining highlights the eccrine secretory coil
and did not stain apocrine glands. Anti-CD117 is a strong marker of tumor
epithelium in spiradenomas and hidradenomas. Anti-CD117 highlights cylindroma
ductal structures well. Syringomas and poromas resulted in the most negative tumor
and ducal epithelium staining.
Commercial support: None identified.
Commercial support: None identified.
P8446
P7828
Angiosarcoma presented as skin-colored papules
Eun Ah Suhng, MD, Department of Dermatology, School of Medicine, Ewha
Womans University, Seoul, South Korea; Hae Young Choi, MD, PhD, Department
of Dermatology, School of Medicine, Ewha Womans University, Seoul, South
Korea; Ji Yeon Byun, MD, PhD, Department of Dermatology, School of Medicine,
Ewha Womans University, Seoul, South Korea; Ju Yun Woo, MD, Department of
Dermatology, School of Medicine, Ewha Womans University, Seoul, South Korea;
Seung Hyun Cheong, MD, PhD, DS dermatology and laser clinic, Seoul, South
Korea; You Won Choi, MD, PhD, Department of Dermatology, School of
Medicine, Ewha Womans University, Seoul, South Korea
Angiosarcomas of the face and scalp in the elderly usually present as bruise-like
patches or violaceous nodules but variable clinical features are demonstrated. A
77-year-old man presented with skin-colored papules on the scalp. Clinically, benign
appendageal tumors were suspected, but the histopathologic examination revealed
moderately differentiated angiosarcoma. The dermis was infiltrated by irregularly
anastomosing vascular channels lined by moderately differentiated enlarged
endothelial cells permeating between collagen bundles. Atypical and hyperchromatic cells were frequently encountered. After wide excision and skin grafts, 2 more
similar papules developed at 1-year follow-up. Rebiopsy revealed the multifocal
appearance of angiosarcomas. Clinicians should not exclude angiosarcoma in the
differential diagnosis even though the color is not suggestive of vascular origin when
the lesions develop on the face and scalp in elderly patients. We add an unusual
presentation of angiosarcoma manifested as skin-colored papules.
Commercial support: None identified.
AB72
Claudins expression profile in squamous cell carcinoma of
epidermodysplasia verruciformis
Claudia Kwei Fong Dai Tanabe, MD, Department of Dermatology, Medical
School, University of S~ao Paulo, S~ao Paulo, Brazil; Ilana Halpern, MD,
Department of Dermatology, Medical School, University of S~ao Paulo, S~ao
Paulo, Brazil; Lana Luiza da Cruz Silva, MD, Department of Dermatology,
Medical School, University of S~ao Paulo, S~ao Paulo, Brazil; Mayra Servilha Grion
Mattos, MD, Department of Dermatology, Medical School, University of S~ao
Paulo, S~ao Paulo, Brazil; Mirian N. Sotto, MD, Department of Dermatology,
Medical School, University of S~ao Paulo, S~ao Paulo, Brazil; Walmar Roncalli
Pereira Oliveira, MD, Department of Dermatology, Medical School, University of
S~ao Paulo, S~ao Paulo, Brazil
Objective: Evaluate and compare the profile of claudins 1, 3, 4, 5, 7, and 11
expressed in squamous cell carcinoma (SCC) in patients with and without
epidermodysplasia verrucifomis (EV).
Methods: This study examined and compared claudins expression in 32 specimens
of SCC in EV patients and 31 cases of SCC in control group, by using a panel of
anticlaudin antibodies (anticlaudins 1, 3, 4, 5, 7, and 11) organized in a tissue
microarray.
Results: In both groups, claudins 1, 3, 4, 5, 7, and 11 expressed a diffuse or focal
pattern and were mostly localized in the membrane of positive cells. Claudins 7
and 11 in SCC from EV patients exhibited a higher frequency of the focal pattern
(P \.05) when compared to patients without the viral disease. Both groups showed
the same expression pattern of claudins 1, 3, 4, and 5.
Conclusions: Patients with EV that develop SCC may display a predominant focal
expression of claudin 7 and 11, which could be interpreted as a down-regulation of
these claudins. This pattern might be associated with the locally aggressive
behaviour of these tumors.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P8093
P7682
Clinical and histopathologic study of benign lichenoid keratosis on the
face
Kwang Ho Kim, MD, Hallym University Sacred Heart Hospital, Anyang, Gyeonggido, South Korea; Jong Hyun Yoon, MD, Hallym University Sacred Heart Hospital,
Anyang, Gyeonggi-do, South Korea; Min Seok Kim, MD, Hallym University Sacred
Heart Hospital, Anyang, Gyeonggi-do, South Korea
Benign lichenoid keratosis is a cutaneous entity that consists of a nonpruritic papule
or slightly indurated plaque that is histologically characterized by a band-like
inflammatory infiltrate with interface involvement. The purpose of this study was to
investigate the clinical and histopathologic features of benign lichenoid keratosis
localized on the face. Fourteen benign lichenoid keratosis patients diagnosed
clinically and histopathologically in our clinic during the 10-year period (2002-2012)
were studied. Thirteen female and 1 male patients were included. The mean age at
diagnosis was 46.5 years. The color of most of the lesions was brown (10 cases,
71%). The cheek was the most commonly involved area (10 cases, 71%). All of the
lesions were single. There were 9 (64%) flat lesion cases and 5 (36%) raised lesion
cases. Most patients denied having any symptoms; 3 had mild pruritus. The
histopathologic finding indicated that all the cases exhibited lichenoid inflammatory
infiltrate obscuring the dermoepidermal junction and vacuolar alteration of basal
cell layer. The lesions showed focal parakeratosis (79%), melanophages (79%),
hyperkeratosis (71%), and necrotic keratinocytes (71%). Solar elastosis (50%) and
acanthosis (43%) were also seen frequently. Diagnosis of benign lichenoid keratosis
should be made by a combination of clinical manifestations and histopathologic
findings. In particular, benign lichenoid keratosis should be considered if a middleaged patient presents a solitary asymptomatic brown lesion on the face. We think
benign lichenoid keratosis may be a specific disorder rather than the inflammatory
stage of regressing solar lentigines, large cell acanthoma or reticulated seborrheic
keratosis.
Histopathology in distinction of lichen planopilaris and central
centrifugal cicatricial alopecia
Palinee Rattanasirivilai, MD, ScD, Boston University, Boston, MA, United States;
Lynne Goldberg, MD, Boston University, Boston, MA, United States
Commercial support: None identified.
Background: Lichen planopilaris (LPP) and central centrifugal cicatricial alopecia
(CCCA) are lymphocytic scarring alopecias. They share overlapping clinical and
histopathologic findings. The goal of this study was to identify reliably distinguishing
histopathologic features between these 2 conditions.
Methods: A retrospective cross-sectional data analytic review of histologic features
from patients identified by diagnosis of LPP or CCCA was designed. Hair Data
Repository and records of the Skin Pathology Laboratory at Boston University were
used to select patients diagnosed with either LPP or CCCA between January 1, 2000
and December 31, 2011. Horizontal sections at level of the infundibulum, isthmus,
and inferior from scalp biopsies of 24 patients (19 CCCA and 5 LPP) were analyzed.
Data on select histopathologic features those might contribute to distinguishing
CCCA from LPP were collected, including the presence of epidermal involvement,
the number of hair follicles, the number of fused follicles, and the number of normal
follicular units, the degree of follicular asymmetry, the degree of perifollicular
fibrosis, the degree of perifollicular inflammation, the degrees of perivascular
inflammation, presence of premature desquamation of inner root sheath, presence
of mucin, presence of naked hair shafts, presence of individual necrotic keratinocytes, presence of intrafollicular lymphocytes, presence of plasma cells, and
presence of dilation of eccrine glands.
Results: The absence of normal follicular units was found in all LPP cases and in 42%
of CCCA cases (P \.05). There was a complete loss of sebaceous glands in 60% of
LPP cases but only in 11% of the CCCA cases (P \.05). Dilated eccrine glands were
found in 10% of CCCA cases compared to 60% of the LPP cases (P \.05). 89% of
CCCA cases had mild or absent perifollicular inflammation, whereas most of the LPP
cases had moderate or severe perifollicular inflammation (P \.05).
Conclusion: CCCA and LPP are lymphocytic scarring alopecia those share many
overlapping findings histologically. Clinicopathologic correlation is always required
for the definite diagnosis. This study found that the findings of unaffected follicular
units, retained sebaceous glands and mild perifollicular inflammation favors a
diagnosis of CCCA, and dilated eccrine glands and heavy perifollicular inflammation
favor LPP.
Commercial support: None identified.
P8540
Hobnail hemangioma on the tongue: Two case reports and a review of the
literature
Rafael Rojo Espa~
na, Hospital U. Morales Meseguer, Murcia, Spain; Amparo Pe~
na
Garcia, Hospital U. Morales Meseguer, Murcia, Spain; Beatriz Perez Suarez,
Hospital U. Morales Meseguer, Murcia, Spain; Eduardo Alcaraz Mateos, Hospital
U. Morales Meseguer, Murcia, Spain; Jose Manuel Rodenas, Hospital U. Morales
Meseguer, Murcia, Spain; Pedro Mercader Garcia, Hospital U. Morales Meseguer,
Murcia, Spain
Introduction: Hobnail hemangioma (HH) is a rare vascular lesion, which manly
affects trunk and limbs. We present 2 cases with tongue involvement and review of
the literature.
Eruptive generalized keratoacanthoma of Grzybowski in an elderly female
Choon Chiat Oh, MBBS, Singapore General Hospital Dermatology Unit,
Singapore, Singapore; Luisa Motta, MD, Salford Royal NHS Foundation Trust,
Salford, United Kingdom
Eruptive generalized keratoacanthoma of Grzybowski is a very rare condition with
few cases reported to date. We report a case of an elderly white female, with no
significant medical history, presenting with sudden and rapid onset of multiple
monomorphic papules over the sun-exposed areas of head, neck and upper trunk.
These lesions demostrated koebnerization. Histology taken from one of the papules
showed features consistent with keratoacanthoma. A diagnosis of eruptive
generalized keratoacanthoma of Grzybowski was made after clinicopathologic
correlation. Some of the lesions have resolved spontaneously and she is kept on
follow-up. Histology features of keratoacanthoma can be challenging, with features
similar to that of squamous cell carcinoma and perforating folliculitis. The clinical
context must be taken in perspective and follow up is recommended for signs of
progression.
Methods: We report a 76-year-old woman and a 51-year-old man presented for
evaluation of a violaceous nodule that appeared on their tongues. It had slowly
enlarged over 1 year in the first case, and 4 months in the second one. The lesions
were asymptomatic, except for periodic bleeding. Lesions were completely
removed surgically.
Results: The histologic examination showed, in both cases, dilated, irregular, thinwalled, telangiectatic vascular spaces in the papillary dermis with papillary
proyections lined by prominent endothelial cells, protruding into the lumen,
leading to the diagnosis of hobnail hemangiomas.
Conclusions: Hobnail hemangioma is an unusual benign vascular lesion showing
peculiar endothelial cells morphology. It was first described as targetoid hemosiderotic hemangioma in 1988. It may be seen in any age, but most patients are in their
20s or 30s. It may be located on skin of the trunk (40%) or extremities (44%), and less
frequently in the head and neck, including the mouth (6%). The differential
diagnosis with some vascular malignant lesions is at times problematic. Etyology of
hobnail hemangioma remains unclear. Physical injury, including injury of a
preexisting hemangioma or ionizing radiations were proposed as causative factors,
as well as increased vascular permeability and leakage of erythrocytes promoted by
chronic inflammation. The gross ‘‘targetoid’’ appearance is suggested to be a result
of microshunts connecting lymphatic vessels and adjacent blood vessels. The typical
hobnail hemangioma is a small targetoid lesion with a central violaceous papule and
surrounding halo that can vary in color from tan to black. The defining feature is the
hobnail morphology of the endothelial cells. Clinical differential diagnosis includes
melanocytic nevus, malignant melanoma, Kaposi sarcoma, hemangioma, solitary
angiokeratoma, dermatofibroma, and insect bite reaction. In summary, we report 2
cases of this rare lesion, important for differential diagnosis with malignant vascular
tumors, localized in one of the rarest places: the mouth; and literature review.
Commercial support: None identified.
Commercial support: None identified.
P7710
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB73
P7761
P8578
Immunohistochemical expression of cytokeratin 15, cytokeratin 19,
follistatin, and Bmi-1 in basal cell carcinoma
Seunghyun Sohng, MD, Yeungnam University Medical Center, Daegu, South
Korea; Byeongsu Kim, Yeungnam University Medical Center, Daegu, South Korea;
Donghoon Shin, Yeungnam University Medical Center, Daegu, South Korea;
Jinhwa Choi, Yeungnam University Medical Center, Daegu, South Korea; Jongsoo
Choi, Yeungnam University Medical Center, Daegu, South Korea; Youngkyung
Bae, Yeungnam University Medical Center, Daegu, South Korea
Merkel cell carcinoma in association with benign follicular structures:
Report of 2 cases
Julia Shlyankevich, MD, Massachusetts General Hospital, Boston, MA, United
States; Daniel Lantz, MD, University of Washington Department of Medicine
Division of Dermatology, Seattle, WA, United States; Evan George, MD, University
of Washington Department of Clinical Pathology, Seattle, WA, United States;
Galina Stetsenko, MD, University of Washington Department of Medicine
Division of Dermatology, Seattle, WA, United States; Paul Nghiem, MD, PhD,
University of Washington Department of Medicine Division of Dermatology,
Seattle, WA, United States; Stevan Knezevich, MD, VA Medical Center
Department of Anatomic and Clinical Pathology, Seattle, WA, United States
Background: Merkel cell carcinoma (MCC) is a rare and aggressive tumor often
presenting as a small painless nodule on sun-exposed skin. Positive staining for
cytokeratin 20 (CK20) in a perinuclear dot like staining pattern on immunohistochemistry is an important diagnostic tool that helps differentiate this neoplasm from
other small basaloid tumors. MCC arising within benign adnexal tumors or cysts is
exceedingly rare. We describe 2 cases of this phenomenon.
Backgrounds: Basal cell carcinoma (BCC) is the most common cutaneous neoplasm.
Despite numerous previous studies, the origin of BCC is still controversial.
Objective: The aim of this study is to evaluate whether BCC arise from the hair
follicle rather than the epidermal basal cell.
Methods: In this study, we examined the expression of the immunohistochemical
(IHC) stainings of CK15, CK19, follistatin, and Bmi-1 in BCC, trichoblastoma, actinic
keratosis (AK), and squamous cell carcinoma (SCC). Twenty cases of histopathologically proven BCC, 13 cases of trichoblastoma, 19 cases of SCC, and 21 cases of
AK were selected from the patients who had visited the Department of Dermatology
of the Yeungnam University Medical Center.
Results: For CK15, labeling indexes of BCC (83.0%) and trichoblastoma (84.4%)
were statistically and significantly higher than that of AK (15.9%) and SCC (15.8%).
Strong positivity (3+ or more) was observed in 85% of BCC, 100% of trichoblastoma,
4.8% of SCC, and 0% of AK. In CK15 staining, BCC and trichoblastoma showed
positivity more frequently than SCC and AK. For CK19, labeling indexes of BCC
(8.1%), trichoblastoma (6.6%), AK (3.5%) and SCC (14.8%) revealed no difference.
For follistatin, labeling indexes of BCC (51.1%) and trichoblastoma (70.1%) were
statistically and significantly higher than that of AK (0.9%) and SCC (8.5%). Strong
positivity (3+ or more) was observed in 50% of BCC, 76.9% of trichoblastoma, 4.8%
of SCC, and 0% of AK. In follistatin staining, BCC and trichoblastoma showed
positivity more frequently than SCC and AK. For Bmi-1, labeling indexes of BCC
(74.4%) and trichoblastoma (84.7%) were statistically and significantly higher than
that of AK (24.7%) and SCC (18.6%). Strong positivity (3+ or more) was observed in
85% of BCC, 84.6% of trichoblastoma, 4.8% of SCC, and 10.5% of AK. In Bmi-1
staining, BCC and trichoblastoma showed positivity more frequently than SCC and
AK.
Conclusion: In this study, positivity of CK15, follistatin and Bmi-1 in BCC and
trichoblastoma was significantly higher than that of SCC and AK. These findings
suggest that BCC and trichoblastoma share the same differentiation toward the hair
follicle. In addition, CK15, follistatin, and Bmi-1 can be useful as markers to
differentiate BCC from SCC.
Case 1: A 61-year-old female presented with a nodule on the right elbow clinically
diagnosed as a benign cyst but with subsequent histopathology revealing an MCC
arising in the wall of, and adjacent to, a trichilemmal cyst. The neoplastic cells
showed typical perinuclear dot-like reactivity to CK20. After sentinel lymph node
biopsy and adjuvant radiation to the primary site, the patient has been recurrencefree for 4 years.
Case 2: A 79-year-old female presented with a small tender nodule on the rim of her
left ear that had grown in size over 3 months and was concerning for a basal cell
carcinoma. Excision and histopathology revealed a trichilemmoma with an in situ
MCC. Immunostaining showed CK20 reactivity characteristic for MCC. Wide local
excision was performed with sentinel lymph node biopsy (negative) and the patient
has been recurrence-free for [1 year.
Discussion: Merkel cells have recently been demonstrated in high concentration in
the infundibulum and isthmus of the hair follicle. We are not aware of a previous
report in the literature of an MCC arising in association with a trichilemmoma. While
MCCs in association with the hair follicle and hair follicle tumors have previously
been thought to be collision tumors, these cases, in particular the in situ nature of
case 2, further support the hypothesis that a subset of MCCs may actually originate
from the Merkel cells of the follicular epithelium. In analogy to other malignant
tumors arising within cystic structures, it is possible that this feature, when
associated with a Merkel cell carcinoma, may be associated with a more favorable
prognosis.
Commercial support: None identified.
Commercial support: None identified.
P8096
P7904
Localized hypertrichosis associated with traumatic panniculitis
Ju Yun Woo, MD, Department of Dermatology, School of Medicine, Ewha
Womans University, Seoul, South Korea; Eun Ah Suhng, MD, Department of
Dermatology, School of Medicine, Ewha Womans University, Seoul, South Korea;
Hae Young Choi, MD, PhD, Department of Dermatology, School of Medicine,
Ewha Womans University, Seoul, South Korea; Ji Yeon Byun, MD, PhD,
Department of Dermatology, School of Medicine, Ewha Womans University,
Seoul, South Korea; You Won Choi, MD, PhD, Department of Dermatology,
School of Medicine, Ewha Womans University, Seoul, South Korea
Hypertrichosis is the overgrowth of hair on any part of the body beyond the normal
limit for a particular age, sex, and race, and can be classified as generalized or
localized. Acquired and localized hypertrichosis can be observed in various skin
diseases, such as Beckers nevus, pretibial myxedema, and also occur secondarily to
drug use and inflammatory diseases. Traumatic panniculitis is characterized by
inflammation and necrosis in the subcutaneous fat after blunt trauma, especially on
the shin. Rarely, localized hypertrichosis is associated with traumatic panniculitis. A
23-year-old woman visited our clinic for a brownish oval-shaped patch covered with
numerous long hair on her right shin. The patch was slightly atrophic and
asymptomatic. Four months ago, she experienced blunt trauma at the same site
on the shin. Although she did not receive any treatment, the excoriated patch
resolved spontaneously and hair had grown at the site of trauma after 2 months.
Incisional biopsy was performed and the biopsy specimen showed infiltrations of
histiocytes and lymphocytes in the subcutaneous fat septum, as well as fat lobule.
Vascular density was slightly increased and focal thrombi in the vascular lumen were
observed in the dermis and the subcutaneous fat tissue. Hair follicle in the dermis
showed no significant histologic change. Herein, we report a rare case of localized
hypertrichosis after traumatic panniculitis.
NY-ESO-1 expression is associated with primary cutaneous melanoma
thickness
Mara Giavina Bianchi, MD, Faculdade de Medicina da Universidade de S~ao Paulo,
S~ao Paulo, Brazil; Cyro Festa Neto, MD, PhD, Faculdade de Medicina da
Universidade de S~ao Paulo, S~ao Paulo, Brazil; Lyn Duncan, MD, Massachusetts
General Hospital, Boston, MA, United States; Miriam Sotto, MD, PhD, Faculdade
de Medicina da Universidade de S~ao Paulo, S~ao Paulo, Brazil
Cutaneous melanoma incidence is increasing at epidemic rates and is associated
with a worldwide increase in melanoma mortality. Advances in targeted therapy and
immunotherapy have revolutionized the treatment of patients with advanced stage
melanoma; nevertheless, there remains a need for reliable therapy that provides a
long-term survival advantage. The cancer-testis antigen NY-ESO-1 is very immunogenic and is a promising candidate for immunotherapy. The study herein examines
NY-ESO-1 antigen expression in primary cutaneous melanoma in the context of
primary tumor characteristics, and patient outcome, including progression and
melanoma-associated mortality. This is a retrospective cohort of 109 melanocytic
tumors including invasive primary cutaneous melanoma (n ¼ 79 in 78 patients),
melanoma in situ (n ¼ 10) and benign melanocytic nevus (n ¼ 20). The invasive
melanomas included a wide range of tumor thickness: \1.0 mm (n ¼ 24); 1.01- 2.0
mm (n ¼ 23); 2.01-4.0 mm (n ¼ 6) and tumors [4.0 mm (n ¼ 26). NY-ESO-1
expression was detected immunohistochemically in 20% of invasive melanoma
(16/79) and less frequently in in situ melanoma (1/10). NY-ESO-1 was not detected in
benign nevi (0/20). NY-ESO-1 expression did not correlate significantly with sex,
race, skin type, age, tumor location, ulceration, sentinel lymph node, progression, or
survival. However, NY-ESO-1 was observed more often in tumors with a measured
thickness of [2.0 mm (P ¼ .02), and less commonly in superficial spreading
melanoma than other melanomas subtypes (P \.02).
Commercial support: None identified.
Commercial support: None identified.
AB74
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P7659
P7765
Primary cutaneous Langerhans’ cell sarcoma: A clinical mimic of
keratoacanthoma
Ariel Burns, MD, Dalhousie University, Halifax, Canada; Noreen M. Walsh, MD,
Dalhousie University and Capital District Health Authority, Halifax, NS, Canada;
Robert Tremaine, MD, Dalhousie University and Capital District Health Authority,
Halifax, Canada
A 62-year-old man, seen by a dermatologist because of a rapidly growing lesion on his
right jawline, was found to have a 3-cm firm erythematous nodule with central
ulceration. A keratoacanthoma was suspected and the lesion was excised.
Microscopically, an undifferentiated malignant tumor occupying the dermis and
subcutis was observed. It was characterized by sheets of discohesive atypical
epithelioid cells with numerous mitotic figures and occasional grooved nuclei.
These focally infiltrated the epidermis and adnexal structures. An initial immunohistochemical panel revealed S100 protein positivity, with negativity for melanoma
markers and cytokeratins. Subsequent studies showed that the tumor cells
expressed CD1a, CD68, CD4, and CD30 (minimally). They lacked CD207
(Langerin), LCA, CD3, CD20, CD21, and lysozyme. Ultrastructural studies on
paraffin-embedded tissue revealed some equivocal structures but definite Birbeck
granules were not found. The initial suspicion of Langerhans cell sarcoma (LSC) was
confirmed on external consultation. Clinical staging revealed no systemic disease.
Further treatment was not initiated and 6 months later there is no evidence of
recurrence. LSC is a rare neoplasm, typically involving multiple sites (eg, skin, lymph
nodes, liver, spleen, lung, and bone). Fewer than 10 cases of LSC arising primarily in
the skin have been reported. It may present as a cutaneous eruption or as a solitary
nodule. It is considered to be an aggressive neoplasm, but the outcomes in published
cases have varied with prognosis dependent on the stage of disease. Excision of
localized disease and/or chemotherapy are used in management. LSC is distinguished from Langerhans cell histiocytosis by its malignant cytomorphology (ie,
cellular atypia, pleomorphic vesicular and often grooved nuclei and numerous
mitoses). It usually has a diffuse growth pattern and often involves epidermal and/or
adnexal epithelium. Identification of this tumor is critically dependant on
immunohistochemistry (usually S100 protein, CD1a, CD4, and often CD207
(Langerin) positive, with relevant negativity vis a vis other S100 proteinepositive
tumors). CD 56 positivity may have adverse prognostic implications. The finding of
Birbeck granules is an additional diagnostic clue. We present this case to increase
awareness of this rare aggressive histiocytic neoplasm, to highlight its characteristic
immunophenotype, and to indicate that it may mimic nonmelanoma skin cancer
clinically and be fatal.
Retiform hemangioendothelioma: A case report of 10 years of evolution
Laia Pastor-Jane, MD, Hospital Universitari Joan XXIII, Tarragona, Spain; Anna
Jucgla- Serra, MD, Hospital Universitari Bellvitge, Hospitalet del Llobregat, Spain;
Antoni Raventos-Estelle, MD, Hospital Universitari Joan XXIII, Tarragona, Spain;
Josep A. Pujol-Montcusi, MD, Hospital Universitari Joan XXIII, Tarragona, Spain
Case report: We report a 51-year-old woman who presented, since 2003,
asymptomatic skin lesions on the lower extremities. On examination, there were
multiple violaceous plaques, slightly infiltrated, very extensive, affecting mainly legs
and ankles and, on lesser extent, thighs and feet. No inguinal lymphadenopathy
were palpable. Skin biopsy showed in the papillary and reticular dermis, a
proliferation of vascular channels of thin walls arranged between the collagen
fibers in an infiltrating pattern. They were lined by a single layer of endothelial cells
with hobnail morphology. Immunohistochemistry showed endothelial cell positivity for CD34 and negative for HHV8. The cell proliferation index with Ki-67 was low
(\1%). These findings were compatible with retiform hemangioendothelioma (RH).
Laboratory examinations including HIV status were negative. Doppler ultrasound,
ruled out an underlying vascular malformation. Chest radiographs, performed
annually have been normal. Abdominal CT scan including groins (last test in June
2013) showed small nonmetastatic bilateral inguinal lymphadenopathy, unchanged
from previous studies. Therapeutic options were discussed: it was unresectable
because of its size and chemotherapy had an unfavorable risk:benefit ratio. Low-dose
radiotherapy supposed technical difficulties and was ruled out by the absence of
disease progression during the years of follow up and the risk of ulceration. We
decided to adopt and expectant management. We are controlling the patient every 6
months with iconography and there have been no changes from the beginning of
our follow-up (2008).
Discussion: RH is an extremely rare low-grade cutaneous angiosarcoma. The
histologic differential diagnosis should be made with hobnail cell hemangioma,
Dabska tumor, and angiosarcoma. It often recurrs after surgical excision but there
are only 2 reported cases of regional lymph node metastasis. No cases of distant
metastasis or tumor-related deaths have been observed. A wide surgical excision is
the treatment of choice. Radiotherapy has been effective in cases with lymph node
metastasis. One unresectable case was successfully treated with external beam
radiation and low-dose cisplatin.
Commercial support: None identified.
Commercial support: None identified.
DIGITAL/ELECTRONIC TECHNOLOGY
P8691
P8541
Report of a collision of malignant melanoma and squamous cell
carcinoma
Claudia Posso-De Los Rios, MD, SKiN Centre for Dermatology, Peterborough,
Canada; Esiahas Amdemichael, MD, Gamma Dynacare, Brampton, Canada;
Gustavo Rubio, MD, SKiN Centre for Dermatology, Peterborough, Canada;
Melinda Gooderham, MD, MS, SKiN Centre for Dermatology, Peterborough,
Canada
We report an uncommon presentation of a collision tumor consisting of an invasive
desmoplastic melanoma in continuity with squamous cell carcinoma in situ. A
66-year-old white male presented with multiple actinic keratoses and a slightly
erythematous pearly papule on the left forehead. Clinically, the lesion was
suspicious for a basal cell carcinoma. A shave excision was performed, followed
by curettage and electrodesiccation. The patient had a history of malignant
melanoma removed with wide excision from the right lower back (Breslow 1.67
mm, Clark level IV) followed by right-sided axillary sentinel node biopsy, which was
negative at the time. Patient was staged at T2A N0 M0, and did not receive additional
ancillary treatment. Medical Oncology then followed him for 1 year without
evidence of any local recurrence or metastatic disease. A physical examination
revealed lentiginous proliferation of atypical melanocytes within the basal layer of
the epidermis, associated with underlying solitary and aggregates of atypical
spindled melanocytes within the dense fibrous stroma with a minimum thickness
of 1 mm, extending to both the deep and lateral margins. There was an adjacent full
thickness keratinocytic atypia with overlying parakeratosis extending to one lateral
margin. S100 stain confirmed that spindled cells were melanocytes. This neoplasm
was interpreted as invasive desmoplastic melanoma with adjacent squamous cell
carcinoma in situ. There are few case reports of patients with coexistence of
malignant tumors composed of malignant epithelial and melanocytic populations.
Our case was classified as a collision tumor because of the presence of 2
phenotypically different neoplasms in close proximity. The precise etiology of
collision tumors is still unknown; a coincidental event and field cancerization theory
are possible explanations. Examples of collision tumors previously reported include
lesions on the lip, cheek, scapula, the nose in a pediatric case with xeroderma
pigmentosum, and the leg in a patient with a burn scar. These lesions may be
clinically and histopathologically difficult to recognize especially if the melanoma
component is amelanotic or desmoplastic type, as was the case here.
Immunohistochemical markers are helpful to identify these malignant tumors.
The report of these cases has been encouraged to determine their frequency and
prognosis. Clinicians and pathologists should be aware of these cases for treatment
and prognosis purposes.
Parallel-polarized light (PPL) photography could enhance the surface reflectance
components of skin and would be a quantitative assessment method for the
examination of the properties of human skin. In our previous study, the quantitative
difference of the light reflected from skin surface could be analyzed by PPL
photography when combined with analytic technique similar to the colorimetric
photography. We designed this study to improve the technique using various LEDs
of different colors. In addition to PPL, in-house skin conductance meter was used to
measure the skin hydration for comparison. A total of 40 healthy subjects were
participated in this study. PPL imaging was taken on 3 sites, mid-cheek, volar aspect
of forearm and anterior shin, using white and green LED illuminators, which had
been proved more adequate than red and blue LED on pilot study. The acquired
images were transformed to CIELAB coordinates, L*, a*, and b*. In order to assess skin
conductance value, we designed probe based on coaxial transmission line basics
and used a sinusoidal wave of 5 KHz. Clinical grading of dryness and glossiness were
made according to the xerosis severity scale and investigator’s global assessment
(IGA), respectively. First of all, as for glossiness on extremities, the L* value
was positively correlated (r ¼ 0.33417), a* and b* value were correlated negatively
(r ¼ -0.32046 and -0.33128, respectively) under the green illuminator. Skin
conductance value was positively correlated with glossiness (r ¼ 0.65258). For
dryness of extremities, the b* under the green illuminator was positively correlated
(r ¼ 0.23339) and negatively with skin conductance (r ¼ -0.80447). Skin
conductance value itself showed correlations with CIELAB coordinate L* and a*
from green light (r ¼ 0.24305 and -0.22102, respectively). In conclusion, analytic
PPL image technique combined with properly chosen LED would be an efficient way
to evaluate the properties of human skin. The results of experiment showed more
productive relevance among each variable than previous study and indirectly
implicated the validity of our in-house conductance meter. These could lead to more
useful and easily accessible tools for dermatologists to examine various biophysical
properties of normal to diseased skin.
Commercial support: None identified.
Commercial support: None identified.
Analytic parallel-polarized light imaging technique using various LEDs for
the examination of skin properties: Comparison with biophysical value
Dai Hyun Kim, MD, Korea University Anam Hospital, Seoul, South Korea; Ga Na
Oh, MD, Korea University Anam Hospital, Seoul, South Korea; Heesang Kye, MD,
Korea University Anam Hospital, Seoul, South Korea; Hyo Hyun Ahn, MD, PhD,
Korea University Anam Hospital, Seoul, South Korea; Jae Eun Choi, MD, PhD,
Korea University Anam Hospital, Seoul, South Korea; Soo Hong Seo, MD, PhD,
Korea University Anam Hospital, Seoul, South Korea; Young Chul Kye, MD, PhD,
Korea University Anam Hospital, Seoul, South Korea
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB75
P7593
P8390
New diagnostic toll for the diagnosis of pigmented skin lesion via
multispectral imaging
Leonardo Pescitelli, MD, Department of Surgery and Translational Medicine,
Section of Clinical, Preventive and Oncology Dermatology, Florence, Italy;
Alessandro Piva, University of Florence, Florence, Italy; Anna Pelagotti, CNRINO, Florence, Italy; Francesca Prignano, MD, PhD, Department of Surgery and
Translational Medicine, Section of Clinical, Preventive and Oncology
Dermatology, Florence, Italy; Gianni Gerlini, MD, Plastic Surgery Unit, Regional
Melanoma Referral Center; Tuscan Tumor Institute (ITT), Santa Maria Annunziata
Hospital, Florence, Italy; Lorenzo Borgognoni, MD, Plastic Surgery Unit, Regional
Melanoma Referral Center, Tuscan Tumor Institute (ITT); Santa Maria Annunziata
Hospital, Florence, Italy; Pasquale Ferrara, CNR-INO, Florence, Italy
A new device for early diagnosis of melanomas has been developed using a
multispectral imaging system acquiring high spatial and spectral resolution images
in the visible, and NIR range. Electromagnetic radiation propagate into the skin and
reache different depths depending on its wavelength, such a system is capable of
imaging layers of structures placed at increasing depths. This allows to image many
properties less or not visible to the naked eye. In collaboration with the Tuscany
Regional Melanoma Referral Center, for each pigmented lesion analyzed, a clinical
and a dermoscopic image and a set of images at different wavelengths were
acquired. Suspicious lesions were removed and histopathologic data were provided.
With the system developed, the pigment network is much better visible, not only
the contrast is increased, but some of the overlaying structure are not present in the
multispectral images related to deeper layers. Moreover, with this new technique,
the main difference detectable between malignant melanomas and healthy nevi is
the fact that in the first case dark structures are still discernible in deeper layers. The
blue-white veil that also represents an important dermoscopic feature in the
diagnosis of melanoma can be easily recognized, by this new technique, since it
become obvious in the presence of a bright-to-dark transition between the
wavebands in the violet to the blue range. Therefore, a new semeiotic is needed
to correctly and accurately describe the content of such multispectral images.
Dermoscopic criteria can be easily applied to describe each image, however
interimage correlation needs new suitable descriptors. New criteria are then
proposed in order to take into account the structure layering. The first set of new
parameters describe how the classic ones, such as area, perimeter, dark area ratio,
etc, vary across different images taken at increasing wavelengths. More features are
then introduced (eg, the longest wavelength where structures can be detected gives
an estimate of the maximum depth reached by the pigmented lesion). While the
presence of a bright-to-dark transition between the wavebands in the violet to blue
range, reveals the presence of blue-whitish veil, and is a further malignancy marker.
Survey of an academic dermatology department with electronic medical
records
Janet Tcheung, MD, Duke University Medical Center, Durham, NC, United States;
Claire Pipkin, MD, Duke University Medical Center, Durham, NC, United States;
Russell Hall, MD, Duke University Medical Center, Durham, NC, United States
Electronic medical records (EMRs) hold the promise of improved patient safety,
efficiency, and productivity, yet many physicians are reluctant to embrace their use.
Barriers to adoption include perception of compromised productivity, ongoing
expense, unreliability, and workflow limitations. Among all subspecialties, dermatology has one of the lowest rates of EMR use; therefore, published literature on the
impact of EMR in dermatology is scarce. A fully functional EMR (Epic), complete
with order-entry and clinical decision support capabilities, was implemented in
October 2012. We conducted an anonymous survey of Duke Dermatology medical
staff to assess the impact of EMR implementation on attitudes and perceptions. We
used a pre/poststudy design and sent a 16-item survey before and 4 months after
implementation. Sixty-three people were surveyed and response rates for baseline
and postimplementation surveys were 65% and 52%, respectively. Respondents
included clinical providers (attending physicians, physician assistants, and residents) and support staff (nurses, medical assistants, and front desk staff); attending
physicians comprised 42% of those surveyed. Among attending physicians surveyed, 79% responded before and 64% responded after implementation.
Postimplementation, 58% felt that documentation in the new EMR was burdensome,
and 87% felt that time spent documenting had increased. More than half of
respondents (53%) felt that patient volume had worsened. In terms of common
functions, including finding clinic notes, prescribing medications, entering laboratory orders, and placing referral requests, the majority of respondents felt that these
functions were worse compared to the previous system. These results are limited by
their timing during the active learning phase of the new EMR but provide important
insights in the perceptions and attitudes of ‘‘front line’’ users. Our staff perceived
negative impacts of the new EMR on aspects of work efficiency and patient
throughput. Future surveys should be implemented to assess the durability of these
initial negative perceptions and capture changes in staff acceptance with the
passage of time.
Commercial support: None identified.
Commercial support: None identified.
P8203
Store-and-forward teledermatology consultations for primary care
providers: A pilot at Henry Ford Health System
Venessa Pena-Robichaux, MD, Henry Ford Health System, Detroit, MI, United
States; Adrienne Choksi, MD, Henry Ford Health System, Detroit, MI, United
States
Background: Dermatology is a specialized field with a high demand fueled by its
current workforce shortage. Unfortunately, this often results in long wait times for
patient appointments. Teledermatology consultations allow for health care providers to exchange patient information (photographs, medical history, etc) via
secured communication technologies and may provide a means to bridge the gap
between patient and dermatologist. In a large state such as Michigan, which has
many rural regions, teledermatology may also serve as way to increase access to
specialized care for patients that live in these areas. We have started a teledermatology pilot within Henry Ford Health System (HFHS) at 6 primary care sites
using a store-and-forward (S&F) model in order to assess patient and provider
feedback and analyze other process measures with an ultimate goal of using this
information to improve the process and extend this service to other areas in
Michigan.
Methods: From September 16, 2012 to June 24, 2013 patients seen by primary care
providers (PCPs) at 6 participating HFHS sites were offered a teledermatology
consultation if they had a non-urgent dermatologic complaint that needed further
evaluation by a specialist. Turnaround time to consult completion, dermatology
referrals avoided, and patient and PCP feedback via survey have been gathered.
Results: Twenty-one S&F teledermatology consults were completed from September
16, 2012 to June 24, 2013. Average turnaround time to consult completion was 2
days and 71% (15/21) of teledermatology consultations did not require a referral to
dermatology. Of all PCPs surveyed, 67% (6/9) responded and 83% (5/6) agreed that
the teledermatology consultation service is a useful resource for their practice, that
it added to their education, and would recommend it to other PCPs. Of all patients
surveyed, 48% (10/21) responded and 90% (9/10) agreed that they were satisfied
with the results of their consultation, would recommend this service to a friend or
family member, and that is an important service offered by HFHS. In addition, of the
patients surveyed 90% (9/10) reported that their skin condition was better.
P8734
Conclusions: Preliminary data suggest that S&F teledermatology consultations may
provide a way to improve access to dermatologic care. PCPs and patients seem to
find teledermatology consultations acceptable and important. As our pilot continues
we are finding ways to improve the efficiency of this service, including integrations
with Epic and iPhone technologies.
Teledermatology, a year of experience at the VA Boston
Neal Kumar, Tufts University School of Medicine, Boston, MA, United States;
Nellie Konnikov, MD, VA Boston Healthcare System, Boston, MA, United States
Teledermatology, defined as the use of secure digital photography, videoconferencing, and data transmission to provide dermatologic care from a distance, has
increasingly become a subject of study in recent years. Both the American Academy
of Dermatology and the American Telemedicine Association have published support
of teledermatology and guidelines to promote the safety, privacy, and efficacy in the
use of teledermatology. As of January 2012, 27% of the 37 active teledermatology
programs in the United States were based at Veterans Administration programs.
Given the prevalence of teledermatology programs in the VA setting, we sought to
analyze the diagnostic accuracy of teledermatology for skin malignancies at the VA in
Boston. Accuracy was defined as matching of teledermatology diagnosis with
histopathology diagnosis. A retrospective analysis was performed using the first year
of teledermatology consults at the VA in Boston from May 31, 2012 to June 3, 2013.
242 cases were conducted during this period using the store-and-forward modality.
Cases were divided into 2 categories: rashes or lumps and bumps. Consults for
rashes were excluded from the analysis so as to only include cases with a potential
for skin cancer. After excluding all rash consults and 2 consults with unacceptable
image quality, 164 cases were eligible for analysis. In 32% of cases (53/164), a biopsy
was recommended for suspicion of malignancy. In 10% of cases (17/164), the
patient was referred to clinic for further evaluation of the need for a biopsy. Out of 53
biopsies recommended, 22 were performed by the time of this analysis (30 days after
the last consult). Seventeen of 22 of the biopsies performed for suspicion of
malignancy were read by a pathologist as positive for skin cancer, for a positive
predictive value of 77%. When the differential given by the teledermatologist
recommending a biopsy only included skin cancer, 12 out of 12 of these biopsies
were skin cancer on pathology. When the differential included both skin cancer and
other nonmalignant entities, 5 out of 7 biopsies were skin cancer on pathology. This
analysis presents potential for continued use as well as improvement of teledermatology for identifying skin cancer from a distance. Limitations included the
first year of experience for staff involved, isolated patient demographic seen at the
VA, and several biopsies not yet performed, which may have altered the predictive
value.
Commercial support: None identified.
Commercial support: None identified.
AB76
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P8181
P8489
Use of a mobile application to provide peer-reviewed acne-related health
education
Diana Cohen, MD, Northwestern University Feinberg School of Medicine,
Department of Dermatology, Chicago, IL, United States; Beatrice Nardone, MD,
PhD, Northwestern University Feinberg School of Medicine, Department of
Dermatology, Chicago, IL, United States; Dennis West, PhD, Northwestern
University Feinberg School of Medicine, Department of Dermatology, Chicago,
IL, United States; Martha Cotton, Northwestern University Segal Design Institute,
Evanston, IL, United States; Pranathi Lingam, MD, Northwestern University
Feinberg School of Medicine, Department of Dermatology, Chicago, IL, United
States; Roopal Kundu, MD, Northwestern University Feinberg School of
Medicine, Department of Dermatology, Chicago, IL, United States
Background: Mobile medical applications (apps) have become commonplace.
However, regulatory oversight in the app marketplace has lagged, leading to
unreliable, and even unsafe, medical apps. We developed a mobile application to
provide users with information from peer-reviewed literature on the topic of dietary
influence on acne. This topic was chosen to offset misperceptions of diet’s role in
acne pathogenesis that are found communicated both through word of mouth and
other available apps. We sought to assess the feasibility of a mobile application for
use as an educational intervention.
Methods: Publications on the topic of diet and acne were identified via PubMed
literature search. The peer-reviewed literature was systemically formulated into a
mobile application, which was made available in English for download free of charge
via the iTunes app store. Included on the app’s home page was a link that opened
the user’s mobile browser to a mobile-formatted, anonymous survey for adults ages
18 and older. The survey was optional for all users of the app, and viewing the app’s
content was not a requisite for survey completion.
Results: In a 90-day period, a total of 65 users completed the survey. During that time,
3,329 new users downloaded the app and 1,870 existing users updated to the current
version of the app, which included the survey link. Of the 65 subjects, 52 female, 43
were age 18-21, and 22 resided in 1 of at least 6 countries outside of the United States.
21 respondents reported they had not seen a doctor for their acne and 57 reported
duration of acne of [1 year. 15 respondents had not yet explored the app, while 25
explored for 5 minutes, 14 for 15 minutes, 5 for 30 minutes, and 6 for [1 hour. 37
respondents found the app by using the search term ‘‘acne’’ in the iTunes App Store.
Other app search terms included ‘‘acne free,’’ ‘‘acne cure,’’ ‘‘diet and acne,’’ and ‘‘acne tips.’’
Conclusion: Mobile apps are increasingly being used as a source of medical
information, including the subject of acne. Despite the highly variable quality for
mobile apps related to dermatology, a well-constructed app based on peer-reviewed
material may be an effective way to disseminate medical information. Mobile apps
typically contain data that maybe suitable for data mining targeted and remote global
populations.
CQI pilot study evaluating the utility of an educational video in the setting
of topical 5-fluorouracil therapy to treat actinic keratoses and its influence
on patient satisfaction
Oma Agbai, MD, University of California, Davis Department of Dermatology,
Sacramento, CA, United States; April Armstrong, MD, MPH, University of
California, Davis Department of Dermatology, Sacramento, CA, United States;
Nasim Fazel, MD, DDS, University of California, Davis Department of
Dermatology, Sacramento, CA, United States; Parastoo Davari, MD, University
of California, Davis Department of Dermatology, Sacramento, CA, United States
Background: Studies have demonstrated that educational videos are beneficial in the
improvement of melanoma awareness and promotion of sunscreen use. Topical 5%
5-FU is an effective treatment for actinic keratosis (AKs). Despite its widespread use,
patient satisfaction rates are low.
Objective: To determine if viewing of an educational video before treatment with 5FU may improve patient satisfaction, treatment adherence, and understanding of
treatment.
Methods: Nineteen (of 44 enrolled) patients with a diagnosis of multiple actinic
keratoses have completed study to date. Ten were randomized to the control group
and 9 randomized to the video group. During a regularly scheduled office visit,
consented subjects in the video group viewed a brief educational video on treatment
expectations and potential adverse effects during and after 5-FU treatment, in addition
to brief verbal counseling by the dermatologist. Subjects in the control group
underwent verbal counseling by dermatologist on the aforementioned subjects, and
did not view the video. After completing 2 weeks of treatment with 5-FU, all subjects
completed a 10-item questionnaire assessing their satisfaction with medical care,
perception of adverse effect severity, efficacy of treatment, understanding of
treatment regimen, and self-reported adherence to the treatment regimen.
Results: When asked about understanding of treatment, 78% in the video group
responded ‘‘excellent’’ or ‘‘very good,’’ compared to 70% in the control group.
Regarding treatment adherence, 89% in the video group reported complete adherence
on at least 11 of the 14 days of treatment, compared to 90% in the control group. When
asked if the subject would recommend this treatment to others, 78% in the video group
reported that they would ‘‘strongly recommend’’ or ‘‘recommend with some confidence,’’ compared to 80% in the control group. In the video group, 100% reported that
they were very satisfied with their dermatologist, as did 100% in the control group.
When asked about overall satisfaction with treatment on a scale from 1 to 100 (100
representing the greatest level of satisfaction), subjects in the video group reported an
average of 78/100, compared to an average of 87/100 in the control group.
Conclusions: Compared to standard counseling, viewing of an educational video
may generate similar levels of patient satisfaction, sense of understanding, and
treatment adherence in management of actinic keratoses with 5-fluorouracil cream.
Commercial support: None identified.
Commercial support: None identified.
EDUCATION AND COMMUNITY SERVICE
P8387
P7636
A critical review of personal statements submitted by dermatology
residency applicants
Jeannette Olazagasti, University of Puerto Rico, School of Medicine, San Juan, PR;
Farzam Gorouhi, MD, University of California, Davis, Sacramento, CA, United
States; Nasim Fazel, MD, DDS, University of California, Davis, Sacramento, CA,
United States
Background: Many applicants believe that a good personal statement will increase
their chances of landing a residency spot. However, there is little evidence of what
role it plays in the residency application review process.
Determining factors impacting rosacea patients’ satisfaction
Bruno Halioua, PhD, Institut Alfred Fournier, Paris, France; Julien Bourcier,
Galderma International, La Defense, France; Marie-Eugenie Alvarez, Galderma
International Market Insights, La Defense, France
Background: Patient satisfaction is the consequence of multiple factors which
influences the patients’ access to healthcare and so the treatment adherence.
Objective: To identify factors associated with satisfaction among patients receiving
care in the treatment of rosacea.
Conclusion: The emphasis of personal statements of the matched residency
candidates were slightly different from the unmatched group, which may suggest
that certain themes may be more desirable. However, the extent of this impact is
currently under investigation and needs to be further elucidated.
Methods: A study was conducted in the UK, France, Germany, and the US, among a
representative sample of patients older than 18 years suffering from rosacea.
Participants were asked to answer 9 questions related to their satisfaction. Each item
was scored on a 10-point scale, ranging from 0 (very dissatisfied) to 10 (very
satisfied). Patient with a score equal to or lower than 4 were considered as
dissatisfied and those equal or upper than 6 were considered as satisfied. KhI2 test
and Student t test were performed to identify factors associated with satisfaction.
Results: A total of 807 patients in Germany, UK, France, and US met the inclusion
criteria and completed the survey. Among them, 237 (55%) consulted a dermatologist. 68.6% were satisfied with dermatologist consultation. The mean patient
satisfaction score towards consultation was 7.04 (median, 2.42). Concerning the
satisfaction of rosacea management, 51.5% patients declared to be satisfied by the
dermatologist’s helpfulness and his willingness to find a solution for their condition,
39% by the efficacy of the treatment, 31.2% appreciated to have the opportunity to
discuss with their dermatologist on the condition and the treatment, and 28.40%
appreciated to talk to a convincing and reassuring dermatologist. As regards the
nature of the information received from dermatologists, 45.1% about the information on available treatments and 39.7% appreciated the information on the condition
and the symptoms. As for the rosacea patient satisfaction, it was linked to the
duration of consultation (positive if [10 minutes; OR, 1.3; P ¼ .02), the type of
examination (positive if closely; OR, 2.3; P ¼ 2.473E-07), the dermatologists’ advice
on their symptoms (OR, 1.7; P ¼ .01239563), the given information on
available treatments (OR, 1.5; P ¼ .00704849), and treatment side effects
(OR, 4.3; P ¼ .0012899). Finally, expected outcomes were a predictor of patient
satisfaction (OR, 2.3; P ¼ .00150803).
Conclusion: During the interaction between patients and physicians, the key
determinant factors of patient satisfaction were counseling, duration of consultation
and the type of examination.
Commercial support: None identified.
Sponsored by Galderma International.
Objective: To investigate the influence of personal statements in successfully matching
into dermatology residency using a comprehensive set of qualitative criteria.
Methods: All dermatology residency applications (n ¼ 332) submitted to UC Davis
Dermatology in the year of 2012 were analyzed. Two investigators blinded to the
match outcome initially analyzed 20 randomly selected personal statements and
defined characteristic themes of content that appeared in at least 1 of the personal
statements. The interrater reliability ([90%) was checked for 50 randomly selected
personal statements and any disagreements were resolved by consensus. The
remaining personal statements were subsequently evaluated by a single investigator
(J.O.). Chi square, Fisher exact, and reliability tests were applied to analyze the results.
Results: The data were compared between the matched versus unmatched
residency candidates. Personal statements mentioning a personal story were less
frequent in the matched group (117/240 [48.8%]) as compared to the unmatched
group (55/92 [59.8%]; P ¼.07). A similar trend was observed for personal statements
mentioning a family member within the field of medicine (9/240 [3.8%] vs. 9/92
[9.8%] and P \.05, respectively). Furthermore, the matched applicants mentioned
the following themes more commonly than the unmatched applicants as their
reasons for going into dermatology: to study the cutaneous manifestations of
systemic diseases (81/240 [33.8%] vs. 21/92 [22.8%]; to better understand the
pathophysiology of skin diseases (20/240 [8.3%] vs. 2/92 [2.2%]; and to contribute
to the literature gap (20/240 [8.3%] vs. 1/92 [1.1%] in the matched and unmatched
groups, respectively; P ¼.05 for all).
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB77
P7551
P8551
Integrating dermatology education into the medical school curriculum:
Creation and evaluation of a clerkship-based curriculum for third-year
medical students
Tara Bronsnick, Robert Wood Johnson Medical School, Somerset, NJ, United
States; A. Yasmine Kirkorian, MD, Robert Wood Johnson Medical School,
Somerset, NJ, United States; Babar K. Rao, MD, Robert Wood Johnson Medical
School, Somerset, NJ, United States; Jisun Cha, MD, Robert Wood Johnson
Medical School, Somerset, NJ, United States; Lilia Correa-Selm, MD, Robert Wood
Johnson Medical School, Somerset, NJ, United States
Our recent survey of 89 fourth-year medical students at Robert Wood Johnson
Medical School (RWJMS) revealed that [50% of senior students lack confidence in
diagnosis and treatment of simple dermatologic conditions. Existing educational
supplements, such as the medical student core curriculum published by the AAD,
are underused, despite high quality content, because of limited awareness of their
existence by medical students and lack of integration into the core curriculum of
medical school. These tools are not convenient for medical student use and do not
effectively fix the deficiency in basic dermatology education. Limited dermatology
education during medical school leads to physicians who feel inadequately prepared
to diagnose and treat common skin disorders and to effectively consult dermatologists. We have created a dermatology curriculum for third-year medical students
that is integrated into the existing clinical curriculum and therefore is uniquely
accessible by students. The course includes an online module to study during each
required clerkship of third year. Clerkship-based organization integrates dermatology education into the existing clinical curriculum and establishes dermatology as
a key component of clinical education. In contrast to existing web-based
supplements, this curriculum is offered as a credit-bearing elective; therefore, it is
well advertised to and easily accessible by students and provides them with an
incentive to participate. Finally, clerkship-based review of dermatology material is
practical for third-year students, who are focused on a specific subject matter for a
limited period, and emphasizes the applicability of dermatology to other fields of
medicine. Sixty-four third-year students will participate in the new dermatology
curriculum at RWJMS during the 2013-2014 academic year. Objective evaluation of
the course’s efficacy includes comparison of pre- and posttests associated with each
module. A postcourse survey will assess students’ perception of the course and
gather feedback. Results from this study will be disseminated to the medical
academic community at large, so that this curriculum may serve as a model for other
medical schools. The poster presentation at the 2014 AAD meeting will include
initial results of this pilot study.
Medicolegal aspects of prescribing dermatologic medications in
pregnancy
Rishu Gupta, Keck School of Medicine of University of Southern California,
Alhambra, CA, United States; Daniel Butler, University of California, San
Francisco, San Francisco, CA, United States; Jenny Murase, MD, University of
California, San Francisco, Department of Dermatology, San Francisco, CA, United
States; Priyank Sharma, Perelman School of Medicine at the University of
Pennsylvania, Philidelphia, PA, United States; Whitney High, MD, JD, University
of Colorado, Department of Dermatology, Aurora, CO, United States
Women frequently use medications during pregnancy, which has the potential to
result in medical malpractice litigation if the fetus is affected by the prescribed
medication. An international study involving about 15,000 women reported that
86% of the women took medications during pregnancy, with an average of 2.9
prescriptions per user. Because of this high prevalence, malpractice litigation poses
a high legal risk to dermatologists who prescribe medications to female patients who
are or may become pregnant. This presentation introduces the medicolegal risks
involved in prescribing dermatologic medications to a pregnant patient and
discusses ways for a dermatologist to mitigate those risks. The current malpractice
and tort laws along with the necessary criteria to establish a malpractice lawsuit are
reviewed. In addition, the results of a search of LexisNexis (the equivalent of
PubMed for lawyers) for cases involving dermatologic medications in pregnancy are
presented. International safety classification systems are also reviewed, and potential high-risk dermatologic medications prescribed in acne, psoriasis, atopic
dermatitis, and connective tissue diseases are discussed. In addition, the presentation summarizes important elements for dermatologists to include, especially in the
era of electronic health records, when documenting their discussion with the
patient. A dermatologist can benefit by being aware of the basics of medical
malpractice and ways to preemptively protect oneself should a lawsuit occur.
Commercial support: None identified.
Commercial support: None identified.
P7630
Knowledge gaps in patient education for long-term systemic
corticosteroids
Christina Correnti, Emory University School of Medicine, Atlanta, GA, United
States; Benjamin Stoff, MD, Emory University School of Medicine, Atlanta, GA,
United States; Leslie Ann Cassidy, Emory University School of Medicine, Atlanta,
GA, United States; Suephy Chen, MD, MS, Emory University School of Medicine;
Department of Dermatology, Atlanta, GA, United States
Objective: To educate patients about long-term ([6 weeks) systemic corticosteroids
(CSs), providers must be aware of patient knowledge gaps. The study objective was
to characterize baseline knowledge of long-term CS treatment among complex
medical dermatology patients.
Methods: Subjects included 102 English-speakers 18 years old with an outpatient
visit from March-June of 2013 at Emory complex medical dermatology clinics. A
12-item questionnaire assessed baseline knowledge. Demographics included age,
sex, ethnicity, first language, and education level. Participants indicated if they had
ever taken systemic CSs in the past. The main outcome was overall knowledge score
difference between prior CS users and nonusers by Student t test. Secondary
outcomes were differences in answer choices between groups. Logistic
regression estimated the odds of scoring more than the lowest 25% of scores
(scoring [5 out of 12).
Results: The mean age of subjects was 52.1 years; 79.4% were white; 51.0% were
female; 32.3% completed 4 years of college; 49% were previous CS users. Mean
overall score was 6.9 6 1.8 out of 12. Mean score for adverse effects questions was
2.9 6 1.3 out of 7. Overall, only 43.1% of subjects correctly identified risk of
osteoporosis (58% of previous CS users) and infection (56% of previous CS users),
and 19.6% failed to identify cataracts as a risk of long-term CSs (20% of users). Only
3.9% thought ophthalmology follow-up was important (6% of users). Previous users
scored significantly higher than nonusers overall (7.5 6 1.6 vs. 6.4 6 1.9; P \.01)
and on adverse effects questions (3.3 6 1.3 vs. 2.5 6 1.2; P \.01). After correcting
for multiple comparisons, a higher proportion of previous users (25% vs. 15%
nonusers) identified osteoporosis as a risk of long-term steroids. Logistic regression
showed significant odds of scoring [5 for previous users versus nonusers (OR, 4.1;
P ¼ .01) and ¼ masters level education versus ¼ 4 years of college education
(OR, 3.5; P ¼.046).
Conclusion: Although half of our subjects had previous treatment with systemic CSs,
knowledge of adverse effects, including osteoporosis and infection, was low. Most
lacking was knowledge of cataract risk and the need for ophthalmology follow-up
with the use of long-term CSs. Recent data suggest cataract risk ranges from 11% to
15% with systemic CS use. Larger baseline knowledge gaps may exist among patients
with 4 years of college education and those na€ıve to CS treatment, which calls for
more focused education for these groups.
Commercial support: None identified.
AB78
P8590
Passion to heal: International dermatology in rural Kenya
Jane Yoo, MD, MPA, Albert Einstein College of Medicine, New York, NY, United
States; Anthony Rossi, MD, JUVA Skin & Laser Center, New York, NY, United
States; Katy Burris Metz, MD, SUNY Downstate, Brooklyn, NY, United States;
Margo Weishar, MD, Springhouse Dermatology, Springhouse, PA, United States
Dermatology, as is practiced in rural parts of the world, remains remarkably limited
given the paucity of resources and infrastructure that is needed to provide such
specialized care. Nevertheless, in Kenya’s Narok South District, home to the Maasai
Mara, skin conditions constitute up to 10% of all clinical cases seen in health clinics.
The Baraka Health Clinic, which currently provides medical care to[40,000 people,
in collaboration with several other organizations, has sought to educate and treat
community members and train local clinicians in dermatology. We present several
interesting case studies of patients treated in the Baraka Health Clinic since its
inception. Some common skin conditions, such as lupus vulgaris, tinea capitis, and
vitiligo may have unique clinical presentations. We also present several dermatologic conditions more prevalent in this area, including hypohydrotic ectodermal
dysplasia, dyskeratosis congenita, filariasis, pellagra, and onchocerciasis. We discuss
their clinical case presentations, work-up, and optimal treatment and management
strategies while working with the local health care team to build their capacity for
diagnosis care of a wide variety of skin conditions.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P7707
P8445
Shade structure use by youth soccer players: An observational study
Kurt Nance, Virginia Commonwealth University, Richmond, VA, United States;
Ian Maher, MD, Saint Louis University School of Medicine, St. Louis, MO, United
States; Sheila Krishna, MD, Virginia Commonwealth University, Richmond, VA,
United States
Use of Internet survey to assess knowledge about skin cancer
Audris Chiang, University of California, Irvine School of Medicine, Irvine, CA,
United States; Gloria Wu, MD, Tufts University School of Medicine, San Jose, CA,
United States; Jenny Nguyen, University of Southern California, Los Angeles, CA,
United States; Kimberly Pham, University of California, Berkeley, Berkeley, CA,
United States; Melissa Howe, California Polytechnic State University, San Luis
Obispo, CA, United States; P Chase Lay, MD, University of Texas Medical Branch
at Galveston, San Jose, CA, United States; Vinna Nam, University of California,
Berkeley, Berkeley, CA, United States
Background: More than 3 million nonmelanoma skin cancers (NMSCs) are
diagnosed annually in the United States, and the incidence of malignant melanoma
(MM) has increased annually by 2.4%. Sun exposure is one of the major risk factors
for developing these cancers, and a significant amount occurs during childhood and
adolescence. That amount of exposure can increase if the child or adolescent
engages in outdoor sports played during the day. Current recommendations for
reduction of UV exposure include wearing protective clothing and sunscreen, and
seeking shade when outdoors. Therefore, providing youth athletes with shade
structures to prevent sun exposure is an important tool in skin cancer prevention.
Objective: To determine the rate of use of shade structures among soccer playing
youths and to determine if this correlates with temperature and UV index.
Study design: Prospective observational study.
Methods: Soccer playing youths were observed during three 1-week outdoor soccer
camps in Richmond, VA. Shade tents were placed near the fields for use during
breaks from play. The number of players using shade structures during rest periods
was counted and compared to the total number at the camp. Correlation between
temperature and UV index with the number of players using the site during break
periods as compared to the total number of camp attendees was also measured.
Results: During the 3 week-long camps, data were gathered for 197 soccer playing
youths over 3 camp sessions. The overall rate of access was of shade structures
during break periods was 76.7%. Throughout the camps, the average temperature
was 84.288F (SD, 2.66).
Conclusion: In this pilot study, we found that shade tents were well used by soccer
playing youths during breaks in play. A 76.67% use rate suggests that shade
structures will be used if provided, which could add to sun-protective behaviors in
this group.
Commercial support: None identified.
Background: Skin cancer is the most common cancer affecting 1 in 5 Americans.
Sunscreen is useful in the prevention of skin cancer.
Purpose: Using an Internet questionnaire to assess public knowledge of skin cancer
and sunscreen use.
Methods: The questionnaire was hosted on Google Forms and posted on social
media Facebook, Tumblr, and Reddit over a 3-month period. Respondents (R) were
¼ 18 years of age and agreed to informed consent.
Results: Total R ¼ 1033: Males (M) 44.6% (461/1033) vs Females (F) 55.4% (572/1033).
Average age 26 6 10 years, range 18-89 years (87% M, 85% F in range 18-30). College or
postgraduate education: M 85.2%; F 93.5%. Questionnaire: Proportion of R having heard
of skin cancer types or symptoms were significantly different: Knowledge of Melanoma
was 24 times more likely than Basal Cell and 49 times more than Squamous Cell (P \
.0001, odds ratio ¼ 23.9; P \.0001, odds ratio ¼ 49.8, respectively; McNemar’s test).
Similarly, Moles were better understood than ‘‘Persistent Sores’’ or growing ‘‘Crusty/Scaly
Bumps’’ as symptoms of skin cancer, with Moles vs Sores (P\.0001, odds ratio ¼ 24.3)
and Moles vs ‘‘Crusty’’ Lesions (P\.0001, odds ratio ¼ 9.7; McNemar’s test). Adherence
to sunscreen was significantly different between genders: M (39.5%) vs F (71.2%) used
sunscreen (P\.001); M 11.7% vs F 14.7% reapplied every 2 hrs (P\.001); M 19.7% vs F
32.5% used 2 tbsp per application (P \.001) (Pearson chi-square). Mean sunscreen
amount applied was 0.95 6 0.74 tbsp. Knowledge and adherence scores: skin cancer
knowledge score (maximum 12 points) mean F 4.79 6 0.09 was significantly greater
than M 3.87 6 0.09 (P \.0001, t test). Knowledge score across education levels was
significant: mean high school score 3.45 6 0.18, college 4.36 6 0.08, postgraduate 4.85
6 0.15 (P\.001, Pearson chi-square). Sunscreen adherence score (maximum 6 points)
mean F 2.35 6 0.06 was significantly greater than M 1.54 6 0.07 (P \.0001, t test).
Conclusions: Our Internet survey showed a lack of knowledge about nonpigmented
skin cancers. We found low adherence for sunscreen use in this population of
internet users. More than 85% of respondents are \30 years old, younger than the
average incidence of skin cancers; however, they are at an age of developing life-long
habits for skin cancer prevention. This group of respondents is also at risk for sun
damage and later development of skin cancer as they age. Therefore, more health
education about skin cancer and sunscreen use would be useful.
Commercial support: None identified.
EPIDEMIOLOGY AND HEALTH SERVICES
ADMINISTRATION
P8626
A cross-sectional study of Fitzpatrick’s skin type and psoriasis in Puerto Rico
Marigdalia Ramirez-Fort, MD, Tufts Medical Center, Boston, MA, United States;
Alice Gottlieb, MD, PhD, Tufts Medical Center, Boston, MA, United States; Hung
Doan, MD, PhD, Tufts Medical Center, Boston, MA, United States; Mark Lebwohl,
MD, Mount Sinai Medical Center, Boston, MA, United States; Shiu-chung Au, MD,
Tufts Medical Center, Boston, MA, United States
Background: Psoriasis morbidity is a known health problem, with a worldwide
prevalence estimated at 2%. Many physicians believe the prevalence of psoriasis
decreases with decreasing latitude; however, Fitzpatrick skin type as it relates to
psoriasis has not been extensively studied. Puerto Rico is a tropical island commonwealth of the United States that suffers a poorly publicized health disparity. This study is
the first report of Fitzpatrick skin type and the epidemiology of psoriasis in Puerto Rico.
P7762
Show and tell: A privately organized dermatology mission to the
Dominican Republic
Shaan Rao, George Washington University, Washington, DC, United States; Babar
Rao, MD, Rutgers- Robert Wood Johnson Medical School, Somerset, NJ, United
States; Omar Noor, MD, Rutgers- Robert Wood Johnson Medical School,
Somerset, NJ, United States; Tara Bronsnick, Rutgers- Robert Wood Johnson
Medical School, Somerset, NJ, United States
Methods: A cross-sectional analysis was performed in Puerto Rico from 2009-2011.
Patient demographics, Fitzpatrick skin type, and dermatologic diagnosis, if
applicable, were collected during 1-day multidisciplinary service missions in 2
distinct geographic locations in Puerto Rico. All patients in these clinics underwent
a full-body skin examination, excluding genitalia. Fitzpatrick skin type and
dermatologic diagnosis was determined for each patient by 1 of 15 American
Board of Dermatologyecertified dermatologists. For clear analysis, ordinal variables
such as skin type were analyzed by bisecting the population into 2 categories; skin
type data fit normality per the Shapiro Wilks test for normality.
Lack of dermatologic care in developing countries is problematic for patients in
whom chronic cutaneous conditions are common and seriously affect quality of life.
This deficiency in care provides an opportunity for dermatologists to make a
significant impact on international public health through medical missions. Here we
describe the preparation for and implementation of a privately organized dermatology mission to the village of Imbert in the Dominican Republic, which may serve
as a guide to other dermatologists who wish to organize a similar trip. During a 2-day
clinic, a total of 279 patients were evaluated and treated. Twenty-four procedures
were performed. The most common diagnoses were eczema, dermatophytoses,
acne, dyspigmentation, folliculitis, and psoriasis. Important factors that contributed
to the success of this mission include facilities provided by the local hospital,
effective advertisements, donated supplies, an efficient medical team, and local
acquaintances of the organizing physician. Potential complications to consider
when planning a mission similar to this include medical malpractice coverage, lack
of laboratory support, limited therapeutic options, and language barriers.
Results: A total of 395 subjects met inclusion criteria. Sex distribution was 270
(69.7%) female and 125 (30.3%) male. The most common Fitzpatrick skin types were
type III (30.6%) and type IV (42.5%). The prevalence of psoriasis was 6.1% (24
patients). Binomial testing showed significant relationships for psoriasis with skin
type (prevalence rate of 3.9% in types 1-3 vs. 7.9% in types 4-6; P ¼ .046) and sex
(prevalence rate of 4.8% male vs. 9.3% female; P ¼ .043).
Conclusion: These data demonstrate that the prevalence of psoriasis in Puerto Rico
(6.1%) is increased as compared to the global population, approaching that of the
Faroe Islands (7.7%). Our results suggest a possible young founder effect. Darker
skin types were more likely to manifest psoriasis clinically than lighter skin types
despite similar genetic factors. Our study highlights a susceptible population in need
of medical attention from subspecialties, such as dermatology. In addition, given the
significantly increased prevalence of psoriasis in darker skin types, despite abundant
natural UV exposure, this subpopulation may benefit from systemic therapies.
Commercial support: None identified.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB79
P7703
P8362
Association between nodular melanoma depth and area-based socioeconomic status, healthcare access, and preventive services use in the United
States
Jacqueline F. Moreau, MS, University of Pittsburgh School of Medicine,
Pittsburgh, PA, United States; Alan Geller, MPH, RN, Department of Society,
Human Development, and Health, Harvard School of Public Health, Boston, MA,
United States; Daniel Winger, MS, University of Pittsburgh Clinical and
Translational Science Institute, Pittsburgh, PA, United States; Laura Ferris, MD,
Department of Dermatology, University of Pittsburgh School of Medicine,
Pittsburgh,
PA,
United
States;
Martin
Weinstock,
MD,
PhD,
Dermatoepidemiology Unit, Veterans Affairs Medical Center, Providence, RI,
United States
Background: Nodular melanoma (NM) accounts for a disproportionate number of
melanoma-related deaths, likely in part because of delayed diagnosis. Several areabased factors (ie, education, income) are predictive of prognosis in the general
population of patients with melanoma. Factors associated with NM prognosis may
differ because of its relatively atypical appearance and rapid growth rate and
consequent ability to metastasize quickly.
Objective: To identify demographic and area-based factors associated with diagnosis
of thick vs. thin NM.
Cost of prevalent psoriasis
Andrew Shors, MD, MPH, Group Health Cooperative, Seattle, WA, United States;
Lisa Williams, MD, MS, Group Health Cooperative, Seattle, WA, United States;
Paul Fishman, PhD, Group Health Research Institute, Seattle, WA, United States
Methods: We conducted a cross-sectional study using data from SEER 18 registries,
2000-2009, and performed multivariable logistic regression using generalized
estimating equations to generate odds of thick ([4 mm) versus thin (\2 mm)
NM. We used demographic traits and county-level socioeconomic status (education,
income), health care access (physician density, health insurance status), and
preventive service use (mammography, Papanicolaou test) as predictors.
Results: We identified 10,475 patients with NM. Living in a county with high
([4/100,000) dermatologist density was associated with decreased odds of thick
versus thin NM (OR, 0.75; P ¼.02). Women ages 18-65 years who lived in counties
with high Papanicolaou test use and women ages 40 years and older who lived in
counties with high mammography use had decreased odds of thick versus thin NM
(OR, 0.60; P \ .001 and OR, 0.68; P \ .001, respectively). Increased age was
associated with increased odds of thick versus thin NM (OR per 5-year increase in
age above the median age (65): 1.11, P \.001), as was Hispanic ethnicity (OR, 1.89;
P\.001). Divorced, separated, and widowed individuals had increased odds of thick
vs. thin NM compared to married individuals (OR, 1.47; P \ .001), as did never
married individuals (OR, 1.63; P \.001). County high school completion, median
income, insurance status, family medicine physician density, and internist density
were not significantly associated with odds of thick versus thin NM.
Conclusions: In contrast to other types of melanoma, NM thickness at diagnosis is
not associated with county-level socioeconomic status. Instead, NM thickness is
related to factors associated with incidental or formal detection. Melanoma
education and early detection programs should incorporate this information and
target counties with low dermatologist density and low preventive service use.
Introduction: We report on the economic consequences of psoriasis by conducting
the first population-based analysis of the incremental cost of prevalent psoriasis that
draws on clinical information from an electronic medical record. In addition to
estimating the incremental costs of prevalent psoriasis we further assess the costs of
specific psoriatic treatments.
Methods: We estimated psoriasis attributable health care costs for all adults, aged 18
and over as of January 1, 2012, that were continuously enrolled in our health plan
and received a diagnosis of psoriasis during 2012. To establish the incremental costs
attributable to psoriasis we identified an adjusted control group from among all
patients without the diagnosis of psoriasis. We estimate health care costs from a
payer’s perspective to measure costs to provide care for members treated for
psoriasis. We use regression models to estimate psoriasis attributable health care
costs. This produces adjusted mean cost values that allow us to test for differences in
health care costs between and among each group.
Results: We identified 2,986 adults that met inclusion criteria and had 2 or more
diagnoses of psoriasis during 2012. Slightly more than half (55.4%) were women and
the mean age of psoriatic patients was 50.5 (SD: 16.8). Mean adjusted total annual
health care costs for patients diagnosed with psoriasis during 2012 were $10,816 (SE
374) compared with $6,772 (SE 188) for controls. The incremental cost of $4,044
attributable to psoriasis is significant at P \.0001. Psoriasis patients treated with
phototherapy had incremental costs of $3,910.17 (P \.0001) relative to all adults
diagnosed with psoriasis while patients treated with biologic agents had incremental
costs of $8,118.98 (P \.0001) relative to patients treated with phototherapy and
cost $12,029 (P \.0001) more than all adults diagnosed with psoriasis.
Conclusion: We report the first population-based analysis of the incremental costs of
psoriasis that used clinical data to establish both the prevalence of psoriasis and the
specific treatments patients received. We document the significant incremental
resources associated with treating adults with psoriasis well as the greater costs
associated with biologic treatments relative to phototherapy. Our study provides
evidence for the potential cost savings that could be achieved with greater use of
phototherapy as a treatment for psoriasis relative to the use of biologic agents.
Commercial support: None identified.
Commercial support: None identified.
P7729
Dermatologic applications of direct-to-consumer genomic analysis
Alexander Fogel, Stanford University School of Medicine, Redwood City, CA,
United States; Jean Tang, MD, PhD, Stanford University School of Medicine,
Redwood City, CA, United States; Kavita Sarin, MD, PhD, Stanford University
School of Medicine, Redwood City, CA, United States; Nason Azizi, MD, Stanford
University School of Medicine, Redwood City, CA, United States
Conclusions: Overall CBCL incidence has stabilized since the early 2000s. The
causes for this trend change are unknown.
Direct-to-consumer (DTC) genomic analysis is highly controversial. Without a
physician’s prescription, patients can order personal genotyping based on more
than one million single nucleotide polymorphisms, and receive genomic information and disease risk assessments based on data from genome wide association
studies. The leading DTC genomic analysis service provides patients with carrier
status for 50 genetic diseases as well as predictions for 21 drug responses, 58
phenotypes, and risk of developing 120 diseases. Proponents of these services argue
that they have the potential to stimulate patient lifestyle change to reduce disease
risk, engage patients in their health care, and alert patients and physicians to
important medical considerations (pharmacogenetics, carrier status). Detractors
argue that these services are of limited value because of the small relative risks of
disease contributed by common genetic variants, have the potential to provoke
anxiety (research suggests otherwise), have shown inconsistencies in disease risk
predictions across companies, have failed to produce major lifestyle changes (diet,
weight loss, exercise) in studies, and are presently of limited clinical utility to
physicians. Irrespective of physician perspectives, [300,000 patients have undergone DTC genomic analysis, and research suggests that upward of one-third of these
patients share their results with physicians. This has important implications to the
field of dermatology, as disease risk predictions from DTC services include a number
of important dermatologic diseases, such as cancer (squamous cell carcinoma, basal
cell carcinoma, melanoma), atopic dermatitis, and hair-loss conditions (alopecia
areata, androgenetic alopecia). It is essential to better understand DTC genomic
analysis within the practice of dermatology. Currently, there is no dermatologyfocused research on the impact of DTC genomic analysis on patients. Also, there has
been no assessment on dermatologists’ familiarity with or opinions of these services.
The Stanford Dermatology Personal Genomics Project seeks to advance this area of
study by enrolling a large-scale cohort of 10,000 patients who have undergone DTC
genomic analysis in an effort to study the impact of these services on patient lifestyle
and behavior, patient psychology and emotional state, medical use, and physician
practice change.
Commercial support: None identified.
Commercial support: None identified.
P7691
Changing incidence trends of cutaneous B-cell lymphoma
Kaveri Korgavkar, VA Medical Center, Providence, RI, United States; Martin A.
Weinstock, MD, PhD, VA Medical Center, Providence, RI, United States
Background: Cutaneous B-cell lymphoma (CBCL) incidence and survival rates have
been increasing steadily for decades. We sought to evaluate changes in CBCL
incidence and survival.
Methods: In this population-based study, CBCL incidence and relative survival rates
were obtained from the 9 original registries of the Surveillance, Epidemiology and
End Results (SEER) program of the National Cancer Institute (NCI) for 1973-2010.
The most recent set of 18 registries were used for incidence and survival data from
2000-2010. The Joinpoint regression program of the NCI was used for trend analysis.
Results: Between 2000-2010, the annual age-adjusted incidence of CBCL was 3.3 per
million persons and the total cases were 2,892. CBCL incidence has increased overall
from 0.7 cases per million persons in 1973-1980 to 3.9 in 2006-2010. However, we
observed that incidence increases have stabilized since 2003 (95% confidence
interval [CI] 1997 to 2005). Before 2003, CBCL incidence increased by 6.9% per year
(95% CI 5.8 to 7.9). Between 2003 to 2010, annual percent change (APC) was 0.3%
(95%CI -4.1 to 4.9). In subgroup analyses, a similar trend was seen for diffuse large Bcell lymphoma, men and whites, while incidence in other subgroups either
continued to increase (women, age 70-84, all other histologic subtypes combined)
or were unable to be analyzed because of small numbers (all other ages, black race,
all registries). Five-year survival rates from CBCL have continued to increase since
1973.
AB80
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P7807
P8427
Diagnostic accuracy of referring providers sending patients to
dermatology urgent care clinic for suspected skin cancers
Julia Shlyankevich, MD, Massachusetts General Hospital, Boston, MA, United
States; Alexandra Kimball, MD, MPH, Massachusetts General Hospital, Boston,
MA, United States; Kristen Corey, MD, Massachusetts General Hospital, Boston,
MA, United States; Marisa Kardos, MD, Massachusetts General Hospital, Boston,
MA, United States
Background: To address the issue of long wait times faced by patients with urgent
medical dermatologic concerns, a dermatology urgent care clinic (UCC) was
established at Massachusetts General Hospital in July 2008. The service is designed
to provide patients, electronically referred by primary care physicians with timely
access to care. Previously reported data from 2008 and 2010 has suggested that a
majority of the referrals to UCC may not be urgent and that diagnostic accuracy of
referrals is low. Here we present additional data including analysis from 2012, as well
as an evaluation of the diagnostic accuracy of referring providers with a focus on
skin cancer.
How pertinent are speciality consultations in patient care?
Sahar Al-Natour, MD, University of Dammam, Al-Khobar, Saudi Arabia
Objective: To determine the diagnostic accuracy for skin cancer of referring
providers to UCC.
Methods: A review of 702 urgent referrals to the Department of Dermatology at
MGH was completed. This included 250 documented urgent referrals from 2008,
250 from 2010, and 202 from 2012. The ICD-9 codes from the respective clinic visits
were obtained, including final clinical and pathological diagnosis. Referrals from
providers that came with a provisional diagnosis of basal cell carcinoma (BCC),
squamous cell carcinoma (SCC), melanoma or a rule-out plus BCC, SCC, or
melanoma were analyzed. Diagnostic accuracy of initial referral compared to the
final diagnosis was calculated for this subset.
Results: A total of 61 provisional diagnoses of BCC, SCC or melanoma were proposed
by referring providers from 2008 to 2012. The diagnostic accuracy for skin cancers
was 34% (21/61). A total of 51 skin cancers (8% of all referral outcomes) were
diagnosed in UCC during the time period evaluated. Twelve of the skin cancers (10
BCCs and 2 SCCs) were found incidentally in patients referred for a different lesion
or rash.
Background: With the worldwide continued increase in the cost of health care
delivery, many question the value/usefulness of frequent referral of patients for
sophisticated tests and procedures and referrals to various specialists and subspecialists. This is a true concern and should be looked into carefully. This issue
cannot be answered by either yes or no, but by looking at specific cases to assess the
value of referrals. Consultant dermatologists, like other specialists, face these issues
repeatedly daily. With every patient that is referred for an opinion or management,
questions arise: ‘‘Was this referral necessary?,’’ and ‘‘Could a nondermatologist
physician have reached the correct diagnosis and management?’’ To answer this, a
sample of recently referred patients’ records were analyzed to determine whether
the referral was indicated for the well-being of the patient.
Methods: Ten cases were randomly chosen from recent referrals to the dermatology
service of a tertiary health facility were closely studied to determine whether the
referral was necessary and beneficial.
Results: The referred cases that were reviewed and included in this study were
found to be patients who were referred for either further evaluation and diagnosis;
those who were misdiagnosed; and those requiring a change of therapy because of
nonresponsiveness. The details of the 10 cases will be discussed. The differences
between dermatologists and nondermatologists, consultants versus nonspecialists
versus residents in training in the evaluation of the individual cases will be discussed.
In each of the cases presented, a knowledgeable consultant was able to establish the
correct diagnosis and adminster the proper/needed treatment; and in some cases,
tissue confirmation was needed.
Conclusion: At least in dermatology, complicated cases and those that do not seem
to be responding to therapies given by nondermatologist practitioners or nonspecialists need to have access to tertiary care specialists. Such referrals are costeffective and improve the patients’ quality of life.
Commercial support: None identified.
Conclusion: Our study revealed that the diagnostic accuracy of referring providers
for skin cancers was low, with 1 in 3 correct diagnoses made. The high number of
malignant neoplasms diagnosed, however, warrants the continued use of an urgent
care clinic as an important triage for patients with acute dermatologic issues. By
recognizing areas of weakness and areas of strength in diagnostic accuracy both
dermatologists and nondermatologists alike will be able to better use the urgent
referral system and ensure timely visits for patients that require them.
Commercial support: None identified.
P7535
Increasing the uptake of herpes zoster vaccinations via community
pharmacies
Leonard Fensterheim, MPH, Walgreen Co, Deerfield, IL, United States; Adam
Cannon, MPH, Walgreen Co, Deerfield, IL, United States; Harry Leider, MD, MBA,
Walgreen Co, Deerfield, IL, United States; Michael Taitel, PhD, Walgreen Co,
Deerfield, IL, United States
P7690
Higher melanoma incidence in coastal versus inland counties in
California
Kaveri Korgavkar, VA Medical Center, Providence, RI, United States; Kachiu Lee,
MD, VA Medical Center, Providence, RI, United States; Martin A. Weinstock, MD,
PhD, VA Medical Center, Providence, RI, United States
Background: Incidence of melanoma is increasing and there is significant variation in
that incidence by geographic location. We sought to measure melanoma incidence
in coastal versus inland counties in California.
Methods: Melanoma incidence data were obtained for 2000-2009 from the 3
registries of the Surveillance, Epidemiology and End Results (SEER) program of the
National Cancer Institute (NCI) that cover the state of California. Incidences for
coastal and inland counties were analyzed using univariable and multivariable
Poisson regression. Additional analyses were performed by stratifying by in situ
versus invasive melanoma, age, thickness, and anatomic distribution, with adjustment for socioeconomic factors (income, race, and education) and latitude.
Results: The total number of cases of melanoma was 63,568 in coastal counties and
30,925 in inland counties. Incidence of in situ melanoma and thin melanoma
( # 1.00) was greater in coastal counties of California than inland counties (IRR,
1.33; 95% CI, 1.13-1.56 and IRR, 1.17; 95% CI 1.02-1.34, respectively), after adjusting
for socioeconomic factors and latitude. There was no increased risk for melanomas
with thickness [1.00 mm in coastal counties versus inland counties.
Conclusions: In melanoma overall, and in in situ and thin melanoma, incidence is
greater in coastal versus inland counties. Causes for this may include differences in
exposures, differences in detection, or artifact, such as residual confounding.
Commercial support: None identified.
Background: Herpes zoster (shingles) is a disease characterized by a painful skin rash
and blistering. The United States has an estimated 1 million cases annually, half of
which occur in the elderly. If untreated, 50% of persons 60 years old develop
postherpetic neuralgia (PHN), a debilitating syndrome that can persist for years. The
Centers for Disease Control and Prevention recommends the herpes zoster vaccine
to persons aged 60 years to reduce the risk of shingles and PHN; however, coverage
levels are estimated at only 15.8%. Physicians typically do not stock the vaccine
because of cost, storage requirements, and limited shelf life. Pharmacists at retail
pharmacies are uniquely positioned to administer these vaccinations and to share
vaccination records with patients’ physicians. Traditionally, pharmacists provided
vaccinations only per physician’s order. Recently, Massachusetts, Florida, and New
York passed legislation allowing pharmacists to administer herpes zoster vaccinations per protocol.
Objective: To investigate the uptake of herpes zoster vaccinations in community
pharmacies and the influence of state-authorized pharmacist immunization privileges on vaccination rates.
Methods: This cross-sectional study analyzed herpes zoster vaccination records from
the Walgreens pharmacy chain. Vaccination rates were calculated as the number of
patients aged 60 years who received a herpes zoster vaccine per 1,000 pharmacy
patients 60 years of age filling a prescription at Walgreens. Rates of vaccinations
were examined 3 months before and after implementation of pharmacist immunization privilege for herpes zoster in Massachusetts (May 2012), Florida (July 2012),
and New York (October 2012).
Results: In Massachusetts, the rate of herpes zoster vaccinations per 1,000 pharmacy
patients increased from 3.3 to 28.1 after expansion of pharmacist privilege, a 745%
increase (P \.001). In Florida, the vaccination rate increased from 3.4 to 16.2, a
377% increase (P \.001). In New York, vaccination rate increased 803% from 1.3 to
11.6 (P \.001).
Conclusions: After the legislation, study pharmacies had a significantly higher rate of
herpes zoster vaccinations. Community pharmacists provided additional access and
convenience to herpes zoster vaccinations for high-risk populations, resulting in
increased uptake. Given the suboptimal vaccination rate of herpes zoster, states
with limited or no immunization authorization for pharmacists should consider
expanding pharmacist privileges.
Financial support for this study was provided entirely by Walgreen Co. All authors
are employees of Walgreen Co.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB81
P7602
P8178
Investigation of patient waiting and processing time in the dermatology
clinic setting
Sarah Koch, MD, MBA, Wake Forest University Department of Dermatology,
Winston-Salem, NC, United States; Amy McMichael, MD, Wake Forest University
Department of Dermatology, Winston-Salem, NC, United States; Lauren Barnes,
Wake Forest University Department of Dermatology, Winston-Salem, NC, United
States
Background: One of the key elements of the patient experience and patient
satisfaction is wait time in the clinic. The majority of the existing literature assessing
the relationship between wait time and patient satisfaction is found within the
literature of nondermatologic specialties. As a shortage of dermatologists leads to an
undersupply of dermatologic services, patient in-office wait time is becoming a
critical issue in the dermatology clinic setting.
Most common dermatologic diagnoses by age in the United States
ambulatory dermatologic care
Erin Landis, Wake Forest School of Medicine, Winston-Salem, NC, United States;
Arash Taheri, MD, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Scott Davis, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Steven Feldman, MD, PhD, Wake Forest School of Medicine, WinstonSalem, NC, United States
Background: While skin diseases vary in patients of different ages, little data exist
about the relative prevalence of dermatologic conditions by age.
Objective: To determine the most common skin conditions in different age groups
seen by dermatologists in the United States.
Purpose: The purpose of this study is to investigate and uncover any bottlenecks or
other causes of delay in the course of processing patients through an academic
dermatology clinic.
Methods: Time points of various steps in the dermatology patient encounter from
check-in to time seen by physician were recorded for all patient encounters for three
months. Three weeks of data were randomly selected for analysis.
Results: For the primary outcome, ‘‘check-in to MD,’’ the average wait time was 33.0
minutes (range, 1-123), and the independent variables which were found to be
significant included time of day, provider, day of week, and week. The number of
patients seen per clinic per week was found to have a significant positive
relationship with the ‘‘chart on door to MD’’ wait time (P ¼ .01) and the ‘‘check-in
to MD’’ wait time (P ¼ .02).
Limitations: This study did not include analysis of arrival time before reception
check-in or the time of check-out. In addition, this study did not differentiate new
patients from return patients, which may be a factor that contributes to increased
wait times. Because of limited patient satisfaction data points, this study was not able
to uncover a relationship between wait times and patient satisfaction.
Conclusions: This data has uncovered bottlenecks which will allow our department
to provide feedback to providers and to make administrative changes in order to
improve clinic wait time. This method of wait time analysis could be applied to any
dermatology practice looking to improve wait time in the clinic setting.
Methods: The National Ambulatory Medical Care Survey (NAMCS) was queried for
top diagnoses at dermatologist visits from 1993-2010.
Results: There were 588 million estimated visits to dermatologists in the US from
1993-2010. In order of frequency, atopic dermatitis, contact dermatitis, and
molluscum contagiosum were the most frequent diagnoses for 0-4 year age group;
acne, viral warts, and benign neoplasm of skin for age 5-24; acne, benign neoplasm
of skin, and contact dermatitis for age 25-44; actinic keratosis, benign neoplasm of
skin, and contact dermatitis for age 45-54; actinic keratosis, seborrheic keratosis, and
contact dermatitis for age 55-64; actinic keratosis, nonmelanoma skin cancer, and
seborrheic keratosis among those age 65 and older. Contact dermatitis and benign
neoplasm were among top 10 most common diagnoses in all groups.
Limitations: While the NAMCS is based on a sample of outpatient visits in the United
States, it cannot directly measure prevalence.
Conclusions: Dermatologic conditions seen in different age groups vary. While
dermatitis is a common condition in all age groups and skin cancer in the older
patients, benign neoplasms of the skin are very common among young and elderly
patients.
The Center for Dermatology Research is supported by an unrestricted educational
grant from Galderma Laboratories, L.P.
Commercial support: None identified.
P7790
Patient-Reported Outcomes of Electrodesiccation & Curettage for
treatment of Nonmelanoma Skin Cancer
Elyse Galles, University of Iowa Carver College of Medicine, Iowa City, Iowa,
United States; Eleni Linos, MPH, PhD, University of California San Francisco, San
Francisco, CA, United States; Mary-Margaret Chren, MD, University of California
San Francisco, San Francisco, CA, United States; Rupa Parvataneni, MS, University
of California San Francisco, San Francisco, CA, United States; Sarah E. Stuart,
University of California San Francisco, San Francisco, CA, United States; Sungat
Grewal, The Commonwealth Medical College, Scranton, PA, United States
Background: The 5-year recurrence rate of nonmelanoma skin cancer (NMSC) after
electrodesiccation and curettage (ED&C) is low (\5%), but patient skin-related
quality of life does not improve after ED&C as it does after excision and Mohs
micrographic surgery. Little is known about other patient-reported outcomes
(PROs) of ED&C for NMSC. We compared a variety of PROs following ED&C to
those following excision and Mohs micrographic surgery.
P8007
Methods: We selected 717 patients who completed PRO surveys from a prospective
cohort of 1536 patients diagnosed with NMSC from 1999-2000. We measured
judgment of cosmetic appearance, bother from appearance, bother from scar,
treatment worth, and overall treatment satisfaction after 1 year using global items
with 1-5 or 7 options. We also used the 18-item Patient Satisfaction Questionnaire
(PSQ-18) adapted for NMSC treatment to measure domains of patient satisfaction
after 3 months. We used the chi-squared test to compare groups for categorical
variables and the Wilcoxon rank sum test for continuous variables. We used
multivariable logistic regression models to determine if treatment predicted better
or worse PROs after dichotomizing PROs at the median and adjusting for age, gender,
number of NMSCs at presentation, tumor size, tumor location, basal cell versus
squamous cell carcinomas, invasive versus superficial histopathology, practice
location, and training level of the treating clinician.
Results: The response rate for PROs varied from 66% to 87%. ED&C patients judged
the posttreatment appearance as worse than those treated with excision or Mohs
micrographic surgery (3.4 6 1.2 vs. 3.7 6 1.1; P ¼ .003).This finding remained in
adjusted analyses: patients treated with ED&C were 2.3 times more likely to report
worse appearance (P ¼ .02). Patients treated with ED&C were no more likely,
however, to be bothered by the appearance after treatment, and in adjusted
analyses, treatment was not an independent predictor of bother from scar, treatment
worth, or overall treatment satisfaction (all P values ¼ .22). Similarly, treatment was
unrelated to general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with the physician, and accessibility and
convenience (all P values ¼ .25).
Malignant melanoma and Spitz nevus incidence in the pediatric
population
Phillip Ecker, MD, Minnesota Dermatology, Plymouth, MN, United States; Amy
Weaver, MS, Mayo Clinic Department of Health Sciences Research Biostatistics
Division, Rochester, MN, United States; Mark Pittelkow, MD, Mayo Clinic
Department of Dermatology, Rochester, MN, United States; Roger Weenig, MD,
MPH, Mayo Clinic Department of Dermatology, Rochester, MN, United States;
Samuel Ecker, DO, Larkin Community Hospital, South Miami, FL, United States;
Xujian Li, MS, Mayo Clinic Department of Health Sciences Research Biostatistics
Division, Rochester, MN, United States
The Rochester Epidemiology Project, a complex array of medical record data and
medical and surgical indexing systems, provides accurate incidence data for diseases
diagnosed in Olmsted County, MN and was used to calculate incidence data for
pediatric melanoma and Spitz nevus. This database includes records from Mayo
Clinic, Olmsted Medical Group, Olmsted Community Hospital, regional hospitals,
nursing homes and private practitioners. All cases of melanoma and Spitz nevus in
persons under 18 years of age were identified from 1950-2004 through the
Rochester Epidemiology Project database. A chart review of [228 charts was
performed to identify clinical characteristics and diagnoses. Review of pathology
was performed by a single dermatopathologist to confirm diagnoses and further
delineate pathologic characteristics. Cases found to be inconsistent with melanoma
or Spitz nevus were excluded from the study. Variables considered included
diagnosis, age, sex, treatment, recurrence, and follow-up time. During 1950-2004,
7 cases of melanoma, 55 cases of Spitz nevus, and 1 case of atypical Spitzoid tumor
were identified. The overall incidence of melanoma was 0.49 per 100,000 persons
(95% CI, 0.1-0.9) and of Spitz nevus was 3.63 (95% CI, 2.7-4.6). The incidence of
Spitz nevus increased significantly from 1990 to 2004 while the incidence of
melanoma remained stable throughout the studied time frame.
Conclusions: ED&C patients judged posttreatment appearance as worse than
excision and Mohs micrographic surgery patients, but bother with appearance
was similar among treatments, as were other PROs. These data inform clinicians
about what to expect after treatment of NMSC with ED&C.
Commercial support: None identified.
Commercial support: None identified.
AB82
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P7692
P8228
Pattern of scalp affection in primary school children in Sohag, Upper
Egypt
Essam-Eldin Nada, MD, Dermatology, Venereology and Andrology Department,
Faculty of Medicine, Aswan University, Aswan, Egypt; Mohammed Moustafa, MD,
Dermatology, Venereology and Andrology Department, Faculty of Medicine,
Sohag University, Sohag, Egypt; Nagah Abo Elfetoh, MD, Public Health and
Community Medicine Department, Faculty of Medicine, Sohag University, Sohag,
Egypt; Samah El Said, MS, Dermatology, Venereology and Andrology Department,
Faculty of Medicine, Sohag University, Sohag, Egypt
Psychiatric morbidity in pruritus associated with no objective dermatologic diagnosis: Results from a nationally representative US sample
Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicine
and Dentistry, University of Western Ontario, London, Ontario, Canada; Aditya K.
Gupta, MD, PhD, Division of Dermatology, Department of Medicine, University
of Toronto, London, Ontario, Canada; Branka Vujcic, Department of Psychiatry,
Schulich School of Medicine and Dentistry, University of Western Ontario,
London, Ontario, Canada
Background: Scalp affection is common in children, especially in schoolchildren.
The objective of this study was to assess the prevalence and pattern of scalp
affection in primary school children in Sohag Province, Upper Egypt during
educational year from September 2009 to June 2010.
Methods: This study included pupils of different age groups between 6 to 12 years in
5 primary schools in Sohag Province. Data collected from all subjects included
sociodemographic data, environmental, and housing data. Complaint, medical
history, family, and past history were obtained from all pupils and examination of the
scalp to detected lesions in school pupils.
Results: Eight hundred twnety-nine of 3,100 pupils (26.7%) had scalp affection:
pediculosis capitis 356 (11.5%), cicatricial alopecia 163 (5.3%), dandruff 147 (4.7%),
tinea capitis 96 (3.1%), impetigo 41 (1.3%), alopecia areata 13 (0.4%), hair loss 10
(0.3%), and psoriasis 2 (0.1%). 23.1% of pupils were affected by 1 scalp disease,
while 3.6% affected by 2 scalp diseases. The highest prevalence rate of scalp
affection (4.8%) was observed in age group (11-12) years. The highest prevalence
rate of scalp affection was observed in girls (15.3%) compared to boys (11.4%). Scalp
affection among urban pupils 23.6% compared to rural pupils 3.1%. The lowest
prevalence rate of scalp affection was detected among pupils belonging to high
socioeconomic class 2.4%, while the prevalence rate 12.3% was observed in low
socioeconomic class and the prevalence rate 12% was observed in middle
socioeconomic class. The highest prevalence rate of scalp affection was among
pupils belonging to a large sized family ([5 persons) 14.8% when compared to 1
belonging to a smaller family (5 persons) 11.9%. The highest prevalence rate of scalp
affection was among pupils washing hair 1 to 3 times per week 17% while the lowest
prevalence rate was detected among pupils washing hair [4 to 6 times per week
9.7%.
Conclusions: This study creates awareness and knowledge about the prevalence and
patterns of scalp affection in primary school children in Sohag Province. Child
education program could be advocated for propagating hygienic habits in schools.
Good training of physician and community health workers in diagnosing and
managing common dermatologic conditions. It is recommended to increase
knowledge, attitude and practice among children regarding scalp diseases in school
health programs.
Commercial support: None identified.
Background: Pruritus is one of the commonest symptoms of dermatologic
disease that is known to be modulated by psychiatric factors, such as depressive
illness. Both peripheral and central nervous system factors are important in the
pathogenesis of pruritus. Higher rates of pruritus have been reported in
psychiatric patients, and pruritus can be a feature of cutaneous sensory disorder
where patients present with pruritus without an apparent dermatologic
disorder.
Objective: Examine the frequency and nature of psychiatric morbidity in
patients from a nationally representative sample in the US, whose main reason
for visit was pruritus with no objective dermatologic diagnosis by the examining
physician.
Methods: Retrospective cross-sectional analysis of 70,276 patient visits from the
National Ambulatory Medical Care Survey and National Hospital Ambulatory
Medical Care Survey from 1995 to 2010, where the reasons for visit were
classified under ‘‘Symptoms Referable to the Skin, Nails, and Hair’’ (1979
National Center for Health Statistics Reason for Visit Classification codes 18301899).
Results: 7.9% 6 0.2% of patient visits (unweighted count ¼ 6,200) were
associated with ‘‘Skin itching’’ or ‘‘Itching of scalp’’; 35% of these visits were not
assigned a dermatologic diagnosis (ICD9-CM codes 680-709) after being assessed
by a physician. Among the pruritus patients without a formal dermatologic
diagnosis, 4.7% 6 0.7% (unweighted count ¼ 99) were assigned a psychiatric
diagnosis (ICD9-CM codes 290-319); the odds ratio (OR) for a psychiatric
diagnosis in this group versus all other visits was 1.91 (95% CI, 1.24-2.96).
The most frequent psychiatric diagnoses were as follows: anxiety disorders (all;
36.5% 6 6.0%); depressive disorders (all, including neurotic depression;
18.0% 6 3.6%); ADHD (9.6% 6 5.9%); obsessive-compulsive disorder (9.2% 6
1.1%); bipolar disorder (7.8% 6 6.5%); and schizophrenia (5.0% 6 2.9%).
None of the visits were associated with a code for suicide or intentional selfinjury.
Conclusion: Our findings from an epidemiologically representative sample
indicate that patients whose reason for visit was pruritus with no subsequent
diagnosis of a primary dermatologic disorder were almost 2 times as likely to
have a psychiatric disorder, most commonly anxiety and depressive disorders.
These findings from a randomly selected sample of patient visits for all
possible disorders, further support the role of psychiatric factors in pruritus
perception.
Commercial support: None identified.
P8566
Prevalence of dermatologic disease in rural Haiti
John Kelly, MD, PhD, Farmington, CT, United States; Anthony Chiaravalloti, SUNY
Upstate Medical University, Syracuse, NY, United States
Background: Few epidemiologic surveys have been carried out to determine the
prevalence of skin diseases in the Haitian population, particularly in rural areas.
Ongoing medical relief trips in the wake of the 2010 earthquake require knowledge
of disease prevalence to adequately supply team members for a successful mission.
Objective: Determine the prevalence of skin diseases in rural, northern Haiti.
Methods: A retrospective medical record review was conducted on data accumulated from February 11, 2013 to February 16, 2013 in Morne Pele, Haiti. There were
1,134 patient encounters with primary care providers occurred over this time
period. Any suspected dermatologic disease was further evaluated by a dermatology
resident or referred to the surgical team for final diagnosis and treatment.
Results: Our data show that 29% of the patients seen were diagnosed with at least 1
dermatologic disease, accounting for 20% of total diagnoses. The majority (48%)
were of a surgical nature (benign adnexal tumors, cysts, or lipomas). The next most
common diagnoses were dermatophyte (15.3%) and helminth (12.7%) infections,
while 7.6% had a nonspecific dermatitis. Less frequently scabies, acne vulgaris,
atopic dermatitis, condyloma, and neurofibromatosis were identified.
Limitations: The triage process may have excluded men and healthier people with
minor dermatologic complaints, skewing our study population significantly toward
women, children, and the elderly. There were limited laboratory and pathology
services to confirm clinical diagnoses.
Conclusions: Dermatologic diseases constitute a significant burden on the rural
population of northern Haiti that medical relief missions to this area should be
prepared to diagnose and treat.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB83
P7754
P8520
Study design for the Stanford Dermatology Personal Genomics Project
Nason Azizi, MD, Stanford University School of Medicine, Redwood City, CA,
United States; Alexander Fogel, Stanford University School of Medicine, Redwood
City, CA, United States; Jean Tang, MD, PhD, Stanford University School of
Medicine, Redwood City, CA, United States; Stanford Medicine, MD, PhD,
Stanford University School of Medicine, Redwood City, CA, United States
US dermatology workforce from 1995 to 2011: A geographic analysis
Lauren Wiznia, Yale University School of Medicine, New Haven, CT, United
States; Jennifer Nam Choi, MD, Yale University School of Medicine, New Haven,
CT, United States
Direct-to-consumer (DTC) genomic analysis is growing rapidly and [300,000
patients have already participated in these services. DTC genomic analysis has
generated significant controversy, because patients order these genotyping and
disease-risk prediction services without a physician’s prescription. Though substantial commentary has been produced on the potential risks and benefits of these
services, little primary research exists to study the impact of these services on
patients and medical practice. The Stanford Dermatology Personal Genomics
Project aims to study the impact of DTC genomic analysis on patient behavior,
risk perception, emotional response, and medical use within the practice of
dermatology. Here, we describe a large-scale cohort study using adapted validated
surveys to investigate the effect of dermatology-relevant DTC genetic risk information on patient behavior, risk perception, physician practice, and medical use.
10,000 participants who have chosen to undergo DTC genotyping will be recruited
from the Stanford Dermatology Clinic. Before testing, participants will complete a
survey to establish baseline skin health practices, knowledge about genetic testing,
perceptions of risks, and motivations for participating. In 1-month follow-up,
participants will receive the results of their genetic risk for skin cancer (melanoma,
squamous cell carcinoma, and basal cell carcinoma), atopic dermatitis, and
androgenetic alopecia and be provided with standardized verbal and written
recommendations on behavioral modifications to reduce the risk of developing
these dermatologic conditions. Follow-up surveys will be automatically sent to
patients’ e-mail accounts at 3 and 6 months to assess behavior change, psychological
well-being, and medical use. To protect patient health information, surveys and
databases are managed using REDCap, a HIPAA-compliant web based application.
Other investigators are encouraged to adapt and modify this study design to further
their own academic efforts.
Commercial support: None identified.
Background: Recent limited growth in the United States dermatology workforce has
paralleled increasing demand for dermatologic services. Despite these concerns,
few studies have examined the supply of dermatologists and their geographic
distribution across the United States.
Objective: We studied the geographic distribution of dermatologists in 1995 and
2011 and investigated population characteristics associated with the current
distribution.
Methods: We analyzed changes in the ratio of dermatologists to the population aged
65 years or older (ROD) among health service areas within the United States. To
determine how the dermatologist distribution compares with that of the primary
care and total physician workforces, we compared the evenness of ROD distribution
with equivalent ratios of primary care physicians (PCPR) and total physicians
(MDR). We also investigated population characteristics associated with the current
dermatologist geographic distribution.
Results: Although the number of dermatologists overall increased, the mean ROD
decreased by 0.20 dermatologists per 100,000 people between 1995 and 2011, from
1.92 to 1.72. Mean PCPR decreased by [18 physicians per 100,000 people. Mean
MDR, on the other hand, increased by [21 physicians per 100,000 people. Gini
coefficient calculations confirmed the maldistribution of the dermatology workforce; dermatologists were less evenly distributed than PCPs and MDs in both 1995
and 2011. Increased ROD was associated with health service areas with lower
unemployment rates (P ¼ .001), higher household incomes (P \.001), and higher
education rates (P \.001).
Limitations: We were not able to determine the ideal distribution of dermatologists,
and our analysis did not capture the impact of nonphysician clinicians, including
physician assistants and nurse practitioners or technological extensions used in
underserved areas. Lastly, our study could not quantify the amount of clinical and
research activity undertaken by each dermatologist.
Conclusion: Despite a modest growth in the dermatology workforce from 1995
through 2011, there remains persistent geographic maldistribution of dermatologists, with a concentration in urban and metropolitan regions. In addition, the
dermatologist distribution was related to regions’ socioeconomic characteristics. To
effectively address workforce issues facing dermatology, we ought to focus not only
on gross numbers of dermatologists but also on their geographic distribution.
Commercial support: None identified.
P8250
P8495
The dermatology consultant: A retrospective analysis of inpatient
dermatology
Christine Ahn, Wake Forest School of Medicine, Winston Salem, NC, United
States; Alyssa Daniel, MD, Wake Forest School of Medicine, Winston Salem, NC,
United States; Gil Yosipovitch, MD, Wake Forest School of Medicine, Winston
Salem, NC, United States; Lindsay Strowd, MD, Wake Forest School of Medicine,
Winston Salem, NC, United States
Introduction: Although dermatology is a largely outpatient specialty, studies have
shown the important role of dermatologists as consultants in the inpatient setting.
However, the impact of dermatology consults on diagnosis, management, and
clinical outcome have not been well described.
Purpose: To determine the frequency and reasons for dermatology consults and
evaluate their impact on diagnosis, management, and outcome.
Methods: All inpatient consults made to the dermatology department at a tertiary
care medical center from 2008 to 2010 were reviewed. Data were collected on
patient demographics, consulting service and preconsult differential diagnoses,
diagnostic tests, and the diagnosis and management established after the consult.
Measures of outcome were hospital length of stay and expiration during the same
hospital stay.
Results: From 2008 to 2010, 1,129 consults were identified and included in the
analysis. The mean age of the patient population was 48.7 years (SD, 28.4) and 46%
were women. The largest numbers of consults were from medicine (46%),
hematology/oncology (25%), and surgery (14%) services. The most common
preconsult diagnoses were unspecified rash (31%), cellulitis (10%), and drug
eruption (7%). After consultation, diagnosis and management were changed in
69.5% of patients. The most common diagnosis was drug eruption (20%), ranging in
severity from minor eruptions to StevenseJohnson syndrome (SJS) and toxic
epidermal necrolysis (TEN), which made up 8% and 4% of drug eruptions,
respectively. Two out of 17 patients with SJS expired during the admission.
Common culprit medications were vancomycin, sulfamethoxazole, and chemotherapeutics. Biopsies aided the diagnosis in 43% of consults, which was higher in
hematology/oncology (65%). The rate of mortality was highest in hematology/oncology patients (10%), and among these patients, 3 of 4 patients with fusarium
infections diagnosed by dermatology expired during the same admission.
Conclusion: Dermatologists contribute significantly to the diagnosis and management of cutaneous disease in the inpatient setting. Despite performing frequent
biopsies, the mortality rate was 2-fold greater in hematology/oncology patients than
in any other service. Although this is a reflection of the complexity of illness and
immunosuppressive states of these patients, the fatality seen with fungal infections
highlights the need for vigilance for opportunistic infections by the dermatology
consultant.
Commercial support: None identified.
AB84
What is it about your skin cancer that bothers you the most? 700 patients
respond
Sungat Grewal, The Commonwealth Medical College, Scranton, PA, United
States; Eleni Linos, MD, PhD, Department of Dermatology, University of
California-San Francisco, San Francisco, CA, United States; Elyse Galles, UI
Carver College of Medicine, Iowa City, IA, United States; Mary-Margaret Chren,
MD, Department of Dermatology, University of California-San Francisco, San
Francisco, CA, United States; Rupa Parvataneni, MS, Department of Dermatology,
University of California-San Francisco, San Francisco, CA, United States; Sarah
Stuart, Department of Dermatology, University of California-San Francisco, San
Francisco, CA, United States
Background: Typical nonmelanoma skin cancers (NMSCs) do not worsen patients’
general health, but whether and how they affect patients’ well-being is poorly
understood. The goal of this study was to understand how untreated NMSCs bother
patients.
Methods: Data were collected from a consecutive cohort of all 1,536 patients with
1,993 histologically confirmed basal cell and cutaneous squamous cell tumors
diagnosed in the Dermatology clinics at the University of California, San Francisco or
the San Francisco Veterans Affairs Medical Center in 1999-2000. Patients with basal
cell nevus syndrome were excluded. This analysis was limited to patients who
responded to the questionnaire before treatment (897 patients with 1,164 tumors).
Of these, 764 patients (85%) responded to the question ‘‘Overall, during the past
week how often have you been bothered by your skin problem?’’ Patients responded
on a Likert scale from 1 to 7, where 7 indicated the greatest bother; we defined
moderate to severe bother as any score [3. Seven hundred patients (78%) answered
the open-ended question ‘‘What is it about your skin problem that bothers you the
most?’’ Descriptions were classified by 2 independent clinicians into 12 categories.
Results: Forty-six percent of baseline responders (412/897) were moderate to
severely bothered by their skin condition. The most common concerns patients
reported included: fear of progression (eg, ‘‘I’m worried that it will spread’’; 14.5% of
patients), appearance (14.2% of patients), concern about having a cancer (10.7% of
patients), skin cancer diathesis (eg, ‘‘I keep getting more of these’’; 7.5% of patients),
and inconvenience (6.4% of patients). Patients also brought up administrative
concerns (eg, ‘‘hard to get an appointment’’; 1.6%), emotional impact of diagnosis
(1.3%), other people’s reaction to the tumor (1.2%), and functional limitations (0.8%).
Twelve percent of patients reported physical symptoms, including itch, burn, pain,
bleeding, and dryness. Itch was the most common physical symptom, reported by
5.5% of patients overall, and 59% of patients reporting physical symptoms.
Conclusions: Many patients with NMSC were bothered by their tumors. Patients
were most bothered by fear of cancer progression and skin cancer diathesis. These
results suggest that patients’ experience of NMSC could be improved by addressing
their fears about prognosis.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
GENODERMATOSES
P8075
A Case of piebaldism misdiagnosed as vitiligo over multiple generations
Jared Heaton, DO, Largo Medical Center, Largo, FL, United States
Piebaldism is a rare genetic pigmentary disorder of autosomal dominant inheritance.
It is characterized clinically by symmetric depigmented patches on the trunk and
extremities, often with a white forelock on the frontal scalp that may involve the
eyebrows. The pathogenesis of this disorder is caused by a mutation in the c-kit
gene, which affects the migration of melanocytes from the neural crest during
embryonic development. The phenotypic severity of the piebaldism depends largely
on the site of mutation within the c-kit gene. We present an interesting case of a 52year-old man with stable depigmented patches on the extremities, chest, and
abdomen since birth. A small white patch of hair on the midline frontal scalp was
also observed. In discussing the patients family history, he stated that his father, 2
brothers, a sister, and his own son and daughter also have stable depigmented
patches in a similar distribution as well as a central white patch of hair. The patient
had been told by both his primary care physician and a previous dermatologist that
he had vitiligo. Piebalsim can be mistaken for other depigmenting disorders and can
easily be mistaken for vitiligo. We highlight other depigmenting disorders including
vitiligo, albinism, and Waardenburg syndrome focusing on the distinguishing
characteristics of piebaldism.
Commercial support: None identified.
P7910
Asymptomatic papules in a young female
Sarah Ellison, West Virginia University, Morgantown, WV, United States; Erica
Ghareeb, MD, West Virginia University, Morgantown, WV, United States; Rodney
Kovach, MD, West Virginia University, Morgantown, WV, United States; Roxann
Powers, MD, West Virginia University, Morgantown, WV, United States
Introduction: Pseudoxanthoma elasticum (PXE) is a rare genetic disorder involving
aberrant mineralization and fragmentation of connective tissue primarily affecting
the skin, eyes, and cardiovascular system. PXE is inherited in an autosomal recessive
pattern, with the majority of cases caused by mutations in the ABCC6 gene encoding
a putative efflux transporter expressed primarily in the liver, kidneys, and intestine.
Cutaneous manifestations of PXE typically develop during childhood as discrete,
yellowish papules that occur on flexural areas and eventually coalesce into
cobblestone-like plaques. More serious complications occur in the third or fourth
decade of life, including angioid streaks of the ocular fundus and blindness and
mineral deposition in the vasculature leading to early atherosclerosis and gastrointestinal hemorrhage.
Case rport: A 22-year-old female presented to our clinic with an irritated skin tag on
the left side of her neck. The patient noted a 7-year history of asymptomatic, fleshcolored papules on her neck. The patient denied any associated ocular, cardiovascular, or gastrointestinal symptoms; but did relate that her sister has similar skin
lesions. The physical examination revealed multiple yellowish, waxy flat-topped
papules on the anterolateral neck and the axilla and antecubital fossa. A skin biopsy
of the lesion from the left side of the neck showed degenerated elastic fibers in the
upper reticular dermis. Von Kossa stains were positive for calcium deposits within
the elastic fibers, confirming a diagnosis of PXE.
Conclusion: PXE is a multisystem disease with cutaneous manifestation often
presenting in the second or third decades of life as highlighted herein. Phenotypic
heterogeneity and lack of serologic markers can make diagnosis difficult. Though
currently there are no known curative treatments for PXE, early diagnosis is critical
to minimize potential complications through careful clinical surveillance and
appropriate genetic counseling and follow-up.
Commercial support: None identified.
P7718
Acute lymphoblastic leukemia in a patient with Cowden syndrome
Aizuri Murad, MBBS, Mater Misericordiae University Hospital, Dublin, Ireland;
Miriam Fitzgerald, MBBCh, Mater Misericordiae University Hospital, Dublin,
Ireland; Niall Mulligan, MBBCh, Mater Misericordiae University Hospital, Dublin,
Ireland; Patricia Lenane, MBBCh, Mater Misericordiae University Hospital,
Dublin, Ireland
A 42-year-old female was referred for a review of hand warts. Clinically, she had
multiple punctate keratoses on her palms and feet associated with multiple firm
papules on her face and ears. A review of her medical history noted that she had
acute lymphoblastic leukemia treated with chemotherapy and bone marrow
transplant in 1989. She had multiple surgeries for a multinodular goiter in 1999
and a panproctocolectomy with permanent ileostomy for extensive polyposis in
2004. She had a cerebral meningioma and cavernoma excised in 2009. An inguinal
cavernous hemangioma was also excised in 2009 and she underwent a wide local
excision for an atypical intraductal papilloma from her right breast in 2010. The
patient had a family history of metastatic breast cancer, gastrointestinal polyposis,
and colorectal cancer. We felt her cutaneous features in association with her
significant medical history were very suggestive of Cowden syndrome. Histologic
examination of multiple biopsies confirmed the presence of punctate keratosis and a
neurofibroma on her palms and feet, while the papular lesions on her face and ears
were seen to be trichilemmomas and trichofolliculomas. The patient fulfilled the
diagnostic criteria according to the National Comprehensive Cancer Network and
genetic testing confirmed the diagnosis with the detection of PTEN gene mutation.
PTEN mutation is identified in approximately 80% of patients with Cowden
syndrome. The PTEN protein is believed to promote cell death and a mutation
may result in overproliferation of cells, resulting in hamartomatous growths. PTEN
has been mapped to 10q23.3, a region disrupted in several human tumors including
haematological malignancies. Its affects are also felt to be caused by a significant role
it plays in the PI3K/AKT/PTEN pathway. We report a patient with Cowden
syndrome, the diagnosis of which was delayed for [20 years from her first attending
medical services because of a lack of recognition of cutaneous signs. Also, to our
knowledge, this is the first reported case in the literature of Cowden syndrome
associated with acute lymphoblastic leukaemia. Recognition of the syndrome and its
many potentially associated diseases has implications for the management of these
patients.
Commercial support: None identified.
P8198
Com
eleNetherton syndrome: A case report
Aline Talarico, MD, PUC-Campinas, Campinas, Brazil; Adilson Costa, MD, PUCCampinas, Campinas, Brazil; Caroline Romanelli Tiburcio Alves, MD, PUCCampinas, Campinas, Brazil; Caroline Silva Pereira, MD, PUC-Campinas,
Campinas, Brazil; Felipe Borba Calixto dos Santos, MD, PUC-Campinas,
Campinas, Brazil; Margareth de Oliveira Pereira, MD, PUC-Campinas,
Campinas, Brazil
The ichthyoses constitute a broad group of cutaneous keratinization changes, which
have the ComeleNetherton syndrome as highlighted for their practically pathognomonic dermatologic findings.
Case report: Male, 18, had been showing diffuse redness and peeling on the body
since he was 3 years old, together with a difficulty in growth during childhood, as
well as thinning and brittle hair and atopic dermatitis for 8 years. Dermatologic
examination showed generalized erythroderma, eczematizations areas in popliteal,
antecubital, and cervical polycyclic scaly areas in the phalanges of the third and
fourth right fingers, hair and eyebrows both thin, rarefied, and brittle. Has growth
retardation (below 5 percentile), elevated serum IgE and osteopenia. Optical
microscopy revealed a trichorrhexis invaginata (bamboo hair). The diagnosis was
ComeleNetherton syndrome, then topic restorative skin barrier were instituted and
sent to endocrinology and genetics.
Discussion: The ComeleNetherton syndrome is the triad: congenital ichthyosis,
trichorrhexis invaginata, and atopy. It is an autosomal recessive disease, secondary
to genetic mutation of the SPINK5 gene, located on chromosome 5q32, which
encodes the LEKT1 (serine protease inhibitor). Loss of activity LEKT 1 alters the
proteolytic function of serum proteases leading to an imbalance of lipids that form
the bilamelar corneum system of the skin. The LEKT 1 is expressed in the cutaneous
lamellar granules and lymphoid tissues, which explains the association between
changes in keratinization and the atopic charge. It is characterized by generalized
erythroderma and peeling shortly after birth. In childhood, linear circumflex
ichthyosis is developed, as well as eczematizations areas and abnormalities of the
hair shaft. The capillary changes are varied, with trichorrhexis invaginata the most
commonly found on the eyebrows. There is an immune imbalance, with increased
serum IgE, peripheral eosinophilia and allergic reactions. Treatment is basically
symptomatic and supportive care in neonatal severe cases.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB85
P8036
P8565
Crouzon syndrome with acanthosis nigricans
Victoria Alegrıa Landa, MD, Hospital Doce de Octubre, Madrid, Spain; Diana
Menis, MD, Hospital Doce de Octubre, Madrid, Spain; Francisco Vanaclocha
Sebastian, MD, Hospital Doce de Octubre, Madrid, Spain; Jimena Sanz Bueno,
MD, Hospital Doce de Octubre, Madrid, Spain; Lidia Maro~
nas Jimenez, MD,
Hospital Doce de Octubre, Madrid, Spain; Raquel Rivera Dıaz, PhD, Hospital
Doce de Octubre, Madrid, Spain; Virginia Sanz Motilva, MD, Hospital Doce de
Octubre, Madrid, Spain
Crouzon syndrome with acanthosis nigricans is a separate entity from Crouzon
syndrome. Clinically, it shares features with the classic Crouzon, such as the type of
craniosynostosis and the other craniofacial phenotype while adding some specific
organ involvement and anomalies of the skin. Genetically it is caused by a single and
specific mutation in the class 3 receptor of the fibroblast growth factor (FGFR3)
different from the several mutations found in the FGFR2 that result in classic
Crouzon. We present 1 case of a 16-year-old girl diagnosed as having Crouzon
syndrome since her early childhood who progressively developed hyperpigmented
velvety lesions over the folds and face during the last 6 years. The recognition of this
distinct craniosynostosis syndrome is important because several organs including
the kidney could be affected. Proper genetic evaluation is mandatory.
Erythrokeratodermia variabilis: A case report
Fernanda Lima, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;
Ana Cerqueira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Fernanda
Craide, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Fernando
Cerqueira, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;
Fernando Rosman, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Marina
Bombardelli, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;
Priscila Bitencourt, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil
A 6-year-old female presenting since age 3 with well demarcated, erythematous, and
brownish keratotic plaques varying sizes, located on the extensor surfaces of the
upper and lower extremities and dorsa of the feet. The keratotic plaques were
presented in bony prominences with palm plantar peeling. Patient refers mild
itching and that cold weather can sometimes exacerbate the condition. There is
history of similar skin lesions in the paternal family. Histopathology revealed
orthokeratotic hyperkeratosis, papilomatosis and dermis unchanged. The physical
examination, histopathologic findings, and family history were consistent with a
diagnosis of erythrokeratodermia variabilis. Erythrokeratodermia variabilis (EKV) is
a rare genodermatosis that has an autosomal dominant mode of inheritance
associated with mutation of GJB3 and GJB4 gens that codifies, respectively,
connexin-31 and connexin-30.3. Both connexins are expressed preferentially in
the keratinocytes of the upper layers of the epidermis. Connexins genes code
proteins that form intercellular channels, called gap junctions that allow for
transport and signaling between neighboring cells in the epidermis. The basic
defect is an abnormality in the keratinocytes cohesion in the stratum corneum. The
disease begins in the first year and presents well demarcated hyperkeratotic areas,
geographically outlined and fixed plaques in a strikingly symmetrical distribution.
The hallmark of EKV is the continual occurrence of transiently, sharply outlined,
figured red patches of variable intensity that fade within a few hours or days. The
histopathologic features of the disease are not specific, consisting of marked
orthohyperkeratosis, irregular acanthosis and variable papillomatosis. The granular
cell layer appears normal. Several case reports suggest the efficacy of oral retinoids.
In cases where oral retinoids are contraindicated, the use of topical keratolitics can
be indicated.
Commercial support: None identified.
Commercial support: None identified.
P7702
Epidermolysis bullosa nevus arising in a patient with DowlingeMeara
type epidermolysis bullosa simplex: Case report and literature review
Laura Patakfalvi, McGill University, Montreal, Canada; Fatameh Jafarian, MD,
Montreal Children’s Hospital, Montreal, Canada; Van Hung Nguyen, MD,
Montreal Children’s Hospital, Montreal, Canada
Epidermolysis bullosa simplex (EBS) is a genodermatosis characterized by skin
fragility with blisters and erosions following minor trauma. Generalized EBS of
DowlingeMeara (EBS-DM) is the most severe form of EBS, and occurs mostly in
children. EBS patients may develop ‘‘EB nevi,’’ which are asymmetric, irregularly
pigmented lesions occurring in the areas of former blisters. Here, we describe the
case of a newborn with extensive blistering and erosions on the skin at birth.
Physical examination revealed multiple herpetiform bulla and erosions on the face,
trunk, upper and lower limbs. The mucous membranes were not affected. There
was marked hyperkeratosis on the palms and soles, as well as nail dystrophy on the
fingers and toenails. Microscopy of the blisters showed noninflammatory intraepidermal blisters with foci of epidermolysis. This intraepidermal type of blister
formation was confirmed by electron microscopy, which showed that the floor of
the blister is composed of the basement membrane, hemidesmosome and some
cytoplasmic portion of the keratinocyte. Immunofluorescence staining was negative
for fibrin, albumin, C3, IgA, IgG, and IgM. Gene analysis revealed L130P missense
mutation in the KRT14 gene. In addition to blisters, our patient developed an EB
nevus. We review 5 previously reported cases of EB nevi occurring in EBS-DM
patients, and discuss its management. Although EB nevi can mimic melanoma, they
are usually benign and could be followed by dermatoscopy.
Familial cylindromatosis
Julie Nguyen, MD, Oklahoma University Health Sciences Center Department of
Dermatology, Oklahoma City, OK, United States; Pamela Allen, MD, Oklahoma
University Health Sciences Center Department of Dermatology, Oklahoma City,
OK, United States
A 65-year-old white female presented to our clinic with a 15-year history of multiple
facial and scalp lesions which have been stable in size. Most of the lesions were
asymptomatic, but a few started to become tender recently both on her scalp and
face. Her medical history was unremarkable. There was no personal history or family
history of skin cancers. However, there was a strong family history of similar lesions.
She stated that her grandmother, mother, aunt, brother, and several cousins have
similar appearing growths on the face and scalp. On examination, multiple firm,
smooth flesh-colored to pink-red papules measuring 5 to 8 mm were seen on the
face and scalp. There was a predilection of lesions on the face for the forehead,
temples, cheeks, periocular, and perinasal regions. Two punch biopsies, 1 each on
the scalp and forehead, both showed basaloid lobules arranged in a jigsaw puzzletype pattern surrounded by thin bands of hyaline material, consistent with
cylindromas. A diagnosis of familial cylindromatosis was made based on clinical
presentation and family history. Familial cylindromatosis is a rare autosomal
dominant condition characterized by multiple cylindromas often present on the
scalp or face. Cylindromas are benign cutaneous adnexal tumors that rarely exhibit
local aggressive behavior or malignant degeneration. Familial cylindromatosis
results from a mutation in the CYLD gene on chromosome 16q, which encodes a
tumor suppressor and deubiquinating enzyme. CYLD gene mutations have also been
described in patients with BrookeeSpiegler syndrome and multiple familial
trichoepitheliomas. Our patient has been referred for genetic testing for confirmation (results pending). The patient is currently undergoing serial punch excisions for
symptomatic cylindromas. She is also scheduled for fractionated ablative CO2 with
us for treatment of the cylindromas on her face. Various treatments for management
of adnexal tumors, such as in multiple trichoepitheliomas, have been reported with
varied results including surgical excision, electrosurgery, and lasers. Very few
reports are available regarding treatment of multiple small cylindromas. We report
an interesting and rare case of familial cylindromatosis and the response of facial
cylindromas to fractional ablative laser (update to be provided soon).
Commercial support: None identified.
Commercial support: None identified.
P7609
AB86
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P8642
P7586
Hyalinosis cutis et mucosae: A case report
Leyla Guzman, MD, Instituto Dermatol
ogico y Cirugıa de piel ‘‘Dr. Huberto
Bogaert Diaz,’’ Santo Domingo, Dominican Republic; Adorabel Diaz, MD,
Instituto Dermatol
ogico y Cirugıa de piel ‘‘Dr. Huberto Bogaert Diaz,’’ Santo
Domingo, Dominican Republic; Bertha Saleta, MD, Instituto Dermatol
ogico y
Cirugıa de piel ‘‘Dr. Huberto Bogaert Diaz,’’ Santo Domingo, Dominican Republic;
Denis Martınez, MD, Instituto Dermatol
ogico y Cirugıa de piel ‘‘Dr. Huberto
Bogaert Diaz,’’ Santo Domingo, Dominican Republic; Elfida Sanchez, MD,
Instituto Dermatol
ogico y Cirugıa de piel ‘‘Dr. Huberto Bogaert Diaz,’’ Santo
Domingo, Dominican Republic; Manuel Valdebran, MD, Instituto Dermatol
ogico
y Cirugıa de piel ‘‘Dr. Huberto Bogaert Diaz,’’ Santo Domingo, Dominican
Republic
Background: Lipoid proteinosis, also referred to as hyalinosis cutis et mucosae or
UrbacheWiethe disease (UWD) is a rare genetic deposition disorder in which
masses of hyaline-like material are deposited not only at mucocutaneous sites but
also in the brain and other internal organs. From the time Urbach and Wiethe gave
the first clear description of the disease, a cumulative total of 250 to 300 cases have
been reported in the literature.
Nevoid basal cell carcinoma syndrome: A treatment conundrum in an
11-year-old African American boy
Stacey Seastrom, DO, Largo Medical Center/NSUCOM, Largo, FL, United States
Case report: A 21-year-old female developed normally until the age of 12, when she
presented at our institution with an atrophic and hyperchromic plaque on her back.
As a young child her voice was hoarse, but it improved in the course of years. About
the same time she presented the full clinical picture of the disease with multiple
discrete and confluent yellowish nodules among the lashes of both eyelids
(moniliform blepharosis). Only after 9 years, when seen again presented with
pigmented punched-out scars of different sizes on her cheeks, as well as major
depression and sublingual mucosal involvement. There were none intracranial
calcifications as usual. A skin biopsy was taken from back skin and palpebral nodules
demonstrating hyalinosis cutis.
Discussion: We report the second case of lipoid proteinosis reported in our
institution of a 21-year-old female that demonstrates the characteristic clinical and
histologic features of the disease, which started at the age of 6.
Nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal dominant,
cancer-predisposing multisystem disorder. The clinical manifestations of NBCCS
include multiple basal cell carcinomas, odontogenic keratocysts, palmar or plantar
pits, and calcification of the falx cerebri. We present a case of an 11-year-old African
American boy who presented with multiple facial lesions and a history of maxillary
keratocysts. Skin biopsy was consistent with pigmented basal cell carcinoma of the
right nasolabial fold. Additional clinical work-up revealed multiple pigmented basal
cell carcinomas, palmoplantar pits, and calcification of the tentorium. Genetic
testing confirmed a heterozygous mutation in PTCH1 gene consistent with NBCCS.
This case presents a very challenging therapeutic and management dilemma in a
Fitzpatrick type V pediatric patient. While the management of NBCCS uses a
multitude of treatment modalities, many of the treatments pose challenges in our
patient due to his propensity for keloid formation and postinflammatory hypopigmentation. Use of multiple therapeutic strategies, in combination with chemoprevention is our mainstay of treatment. Strict adherence to a surveillance protocol
is essential, in addition to use of sun protective measures and minimizing exposure
to ionizing radiation.
Commercial support: None identified.
Commercial support: None identified.
P8031
Response to acitretin in a patient with verrucoid form of HaileyeHailey
disease and presence of human papillomavirus type 6 DNA
Fatima Moreno-Suarez, MD, Santa Barbara Hospital, Puertollano (Ciudad Real),
Spain; Eugenio Sanchez Bastante, MD, Santa Barbara Hospital, Puertollano
(Ciudad Real), Spain; Francisco Jimenez Burgos, MD, Santa Barbara Hospital,
Puertollano (Ciudad Real), Spain; Pablo Bautista Martınez, MD, Santa Barbara
Hospital, Puertollano (Ciudad Real), Spain
Introduction: HaileyeHailey disease (HHD) is a rare automosal dominantly inherited
blistering disease involving the flexural areas. Verrucoid lesions infrequently occur.
Acantholysis is the major pathologic process, and it can be iniciated by friction, UV
radiation, perspiration, and infectious agents. Human papillomavirus (HPV)
infection has been reported to be associated to HHD only in 2 cases in literature.
We report a patient with HHD verrucoid form with concomitant HPV-6 infection
successfully treated with oral acitretin.
Case report: A 43-year-old woman with a 20-year history of HHD, presented with a 1month history of papular lesions on the genitalia area. On physical examination,
multiple verrucoid papules on an erythematous and fisurated base were present at
the inguinal area, bilateral minor and majora labia, and perineum. Histopahtology
revealed hyperkeratosis, parakeratosis, and acantosis with intraepidermal clefting
and acantholysis. No koilocytes or other cytopathic changes were seen. HPV DNA
analysis by polymerase chain reaction (PCR) showed HPV type 6 (HPV6). We made
the diagnosis of verrucoid form of HHD with superimposed of HPV type 6 infection.
Imiquimod and podophyllotoxin treatment did not provide clinical improvement.
Therapy with acitretin 10 mg once a day was iniciated with regression of the lesions.
P8571
Icthyosis follicularis, alopecia, and photophobia (IFAP) syndrome is a rare X-linked
genodermatosis. Mutations of the gene MBTPS2, a membrane-bound transcription
factor protease site 2 gene involved in cholesterol homeostasis and endoplasmic
reticulum stress response, have been recently described. As its name implies, IFAP
syndrome is characterized by icthyosis follicularis, congenital (nonscarring) alopecia
and photophobia. Other clinical features, such as short stature, developmental delay,
seizures, atopic dermatitis, psoriasiform plaques, recurrent infection, and inguinal
hernia are described. Histopathology is nonspecific in IFAP and diagnosis is based on
phenotype and presence of a MBTPS2 gene mutation. We describe a novel missense
mutation in the MBTPS2 gene in this first reported Canadian case of IFAP syndrome.
Discussion: The differential diagnoses of hyperkeratotic papules on the anogenital
region in patient with HHD include verrucoid variant of HHD and condyloma
acuminate. Verrucoid HHD is extremely rare and has a flexural or genital distribution. The morphologic and histopathologic features of our patient were compatible
with verrucoid HHD, presence of HPV infection in the verrucoid lesions favored a
diagnosis of HHD with concomitant HPV-6 infection. Herpesvirus hominis has been
reported to cause a severe exacerbation of HHD. It seems more likely that the HPV
infection play a possible role in the induction of skin lesions. We do not think our
patient had condyloma acuminate because the base of the papular lesions were an
erosive patch of active lesion of HHD. In addition, conventional therapy of
condyloma did not work; however, therapy with acitretin achieved a dramatically
resolution of the lesions. Retinoids have inmunomodulating, antiproliferative,
proapoptotic properties and can stop viral replication. Therapeutic effect of
acitretin in this case, could be attributed to normalization of epidermal differentation and controling the presence of HPV in the lesions.
Commercial support: None identified.
Commercial support: None identified.
Icthyosis follicularis, alopecia and photophobia (IFAP) syndrome: A novel
mutation in MBTPS2 in the first reported Canadian case
Natalie P. Cunningham, MD, Dalhousie University, Halifax, Canada; Scott Murray,
MD, Dalhousie University, Halifax, Canada
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB87
HAIR AND NAIL DISORDERS
P8436
Severe HaileyeHailey disease treated with cyclosporine
Yahya Argobi, MD, Tufts Medical Center, Boston, MA, United States
Background: HaileyeHailey (gamilial benign chronic pemphigus) is a familial
disease characterized by chronic recurrent macerated plaques and erosions. It is
an autosomal dominant disease caused by a genetic defect in a calcium ATPase
(ATP2C1). It usually manifests in early twenties by bullous and vesicular dermatitis
on the intertriginous areas. It can be localized or widespread and secondarily
infected.
Case report: We are reporting a severe case of HaileyeHailey disease responding to
cyclosporine. The patient has HaileyeHailey for [20 years, failed topical steroids,
Carac, systemic antibiotics, Accutane, Soriatane, prednisone, and Enbrel. Patient
reported good result with cyclosporine and 50% of the lesions cleared up within the
first month of cyclosporine.
Conclusion: In conclusion, cyclosporine could be helpful in control of severe
recalcitrant HaileyeHailey disease.
Commercial support: None identified.
P8213
A blinded review of the ongoing SOLUTION study, a phase 2b/3 study of 2
dosing regimens of a novel 10% luliconazole solution in patients with
onychomycosis
Linda Stein, MD, Henry Ford Health Systems, Detroit, MI, United States; Amir
Tavakkol, PhD, Topica Pharmaceuticals, Inc, Los Altos, CA, United States; Hector
Wiltz, MD, FXM Research Corp, Miami, FL, United States; Michael Noss, MD,
Radiant Research, Inc, Cincinnati, OH, United States; Richard Pollak, DPM, MS,
Endeavor Clinical Trials, San Antonio, TX, United States; Steve Kempers, MD,
Minnesota Clinical Study Center, Fridley, Minnesota, United States
Background: Luliconazole is a novel imidazole, and one of the most potent antifungal
agents against Trichophyton rubrum and Trichophyton mentagrophytes. It is
marketed as 1% cream and 1% solution in Japan for the treatment of superficial
mycosis of skin. A 10% luliconazole solution (LS) is being developed for onychomycosis
(OM). In in vitro and in vivo studies, LS is shown to fully penetrate and exhibit potent
activity in healthy and fungus infected human toenail models. In addition, in a phase 1
PK and safety trial LS exhibited low systemic absorption and high nail bioavailability in
patients with moderate to severe OM. A phase 2b/3 dose-finding trial is being
conducted to assess efficacy and safety of this novel formulation in OM patients.
Methods: Subjects, 18-70 years old of any sex and race have been randomized into 4
groups in the US. The first treatment regimen is once a day application for 48 weeks,
and the second is a once a day application for 12 weeks followed by once weekly
application for 36 weeks, and 2 matching vehicle arms (2:2:1:1). Subjects had
clinical diagnosis of mild to moderate distal subungual OM, affecting 25% to 50% of
the nail, and a positive KOH and positive culture. Before subject enrollment, target
toenail screening photographs were reviewed by an independent review committee
of 3 OM experts for adherence to specific protocol entry criteria. All subjects will be
followed for an additional 4 weeks off drug to assess the primary endpoint of
complete cure at week 52. An IRB approved ClinCard program was implemented to
provide subjects with text reminders and educational messages to enhance
retention and compliance with protocol.
Results: Three hundred thirty-four patients have been randomized with 50% having
completed 6 months of treatment. Currently, across study visits, all the tolerability
assessments have indicated no clinically significant findings or AEs. There has been
no pattern of laboratory changes and no serious AE events related to the LS study
medication. We will present demographics, baseline characteristics including age,
sex, and race; percent nail involvement; nail thickness at entry; and other
information. In addition, aggregate, blinded local tolerability, safety data and
comparative susceptibility testing of OM clinical isolates will be presented.
Conclusions: Luliconazole solution 10% is well tolerated by all subjects. Enrolled
subjects have disease severity and demographics similar to recently reported OM
trials.
Supported by Topica Pharmaceuticals.
P8402
Unusual large deletion of ABHD5 gene responsible of DorfmaneChanarin
syndrome in a Moroccan patient
Benjamin Roussel, Li2P EA4222, Bobigny, France; Catherine Prost-Squarcioni,
MD, PhD, Laboratory of Histology, Bobigny, France; Felipe Nery, MD, Department
of Hepatology, Clichy, France; Frederic Caux, MD, PhD, Li2P EA4222, Bobigny,
France; Liliane Laroche, MD, PhD, Department of Dermatology, Bobigny, France;
Olivier Schischmanoff, PhD, Laboratory of Biochemistry, Bobigny, France
DorfmaneChanarin syndrome (DCS) is a rare recessive storage disease characterized by nonbullous congenital ichthyosiform erythroderma (NCIE), liver steatosis,
cataract, and deafness. DCS is associated with diffuse intracellular accumulation of
triglycerides related to mutation of a 7 exons gene, ABHD5. We report a new DCS
patient with an original alteration of ABHD5. A 16-year-old Moroccan male born
from a consanguineous marriage presented with NCIE. Family history revealed that a
maternal cousin had NCIE. Skin examination showed NCIE with diffuse fine grey
scales, dark grey scales on the knees, elbows and dorsal aspect of the hands and
bilateral ectropion. Ocular examination found small lens opacities. Numerous
cytoplasmic lipid droplets were seen in leukocytes on blood smears. Blood tests
revealed raised ASAT, ALAT, ALP, CK, and LDH levels. Liver biopsy demonstrated
steatohepatitis and centrilobular and septal fibrosis without cirrhosis. Cutaneous
biopsy revealed mild acanthosis, orthokeratotic hyperkeratosis and areas of
parakeratosis. Electron microscopy of skin showed cytoplasmic large vacuoles in
keratinocytes, melanocytes, fibroblasts, mastocytes, and smooth myocytes, in favor
of typical DCS. Analysis of patient ABHD5 mRNA demonstrated no amplicon by RTPCR using primers covering the complete transcript and by RT-qPCR. PCR and
sequencing using genomic DNA revealed normal exons 3 to 7 but no amplicons for
exons 1 and 2. A large genomic deletion was suspected. To evaluate the borders of
this deletion, we designed regularly distributed primer pairs from intron 2 to -40,391
bp before the start codon of ABHD5. The limits of the deletion are in progress but
they were around between the middle of intron 2 and -7,079 bp before the ATG,
suggesting the deletion is approximatively 13,000 bp. Currently, 32 mutations of
ABHD5 have been reported including only 2 deletions. The first removed 1,058 bp
and the second 1,487 bp, both at the distal part of the gene. To date, the deletion of
our patient is the largest described in the literature. It deletes the promoter region of
ABHD5 and it is noteworthy that complete absence of ABHD5 expression results in a
typical DCS phenotype similar to other DCS patients with point mutations. In
summary, we reported a novel case of DCS presenting a large deletion of ABHD5.
Dermatologists have to be aware of DCS diagnosis, to be confirmed by blood smears
and ABHD5 analysis and to detect systemic involvement of this serious disorder.
P8592
Commercial support: None identified.
Sponsored 100% by Polichem SA.
AB88
An innovative terbinafine transungual solution (P-3058): A phase 2b dose
finding study in patients with mild to moderate onychomycosis
Robert Baran, MD, Dermatology, Nail Disease Centre, Cannes, France; Federico
Mailland, MD, Polichem SA, Lugano, Switzerland; Linda Frisenda, ScD, Polichem
SA, Lugano, Switzerland; Maurizio Caserini, MD, Polichem SA, Lugano, Switzerland
P-3058, an innovative transungual solution containing terbinafine HCl as active
ingredient and the novel excipient hydroxypropyl chitosan as film-forming agent,
has been developed for the topical treatment of onychomycosis. Mild to moderate
onychomycosis patients (25-60% nail involvement, matrix uninvolved) were randomized to receive 1 out of 5 treatment arms for 52 weeks: P-3058 5% and 10% o.d.,
P-3058 10% o.w., vehicle o.d.or o.w. in a phase 2b dose finding, multicenter,
randomized, double blind, vehicle controlled, parallel-group study. Primary
endpoint was responder rate at 6-month follow up. Secondary endpoints were
complete cure, mycological outcomes, safety, and local tolerability. Overall, 588
were randomized and 370 patients were included in the efficacy analysis: 93 (25.2%)
in 10% o.d., 94 (25.4%) in 5% o.d., 91 (24.5%) in 10% o.w., and 92 (24.9%) in the
vehicle group. Demographic and baseline characteristics were homogenous among
all treatment groups. Patients were predominantly female (60%) and at baseline, the
affected target toenail area was in average 40.7% with overall 6 affected nails. The
responder and cure rates with P-3058 o.w. was definitely clinically relevant being
23.08% and 10.99% achieved after 3 months of follow-up and maintained for another
3 months. Subgroup analysis suggests that age (70) and severity at baseline (50%) are
important prognostic factors increasing the responder and cure rates up to 26.7%
and 12%, respectively. The largest proportion of conversion to negative was
achieved, as expected, by the highest dose regimen, P-3058 10% o.d. (68.82% at
week 64 and 72.13% at week 76). A higher rate of negative culture was recorded in
all groups along treatment course and follow-up. Nevertheless, the difference
among groups was statistically significant at almost all time points during treatment.
As expected, no drug-related adverse events were reported for all treatment groups.
No difference in vital signs and clinical chemistry occurred. In particular, no signs of
hepatotoxicity were noticed. Local irritation was recorded very rarely (0.01%)
during the treatment. Results of this study show that P-3058 10% o.w. is efficacious
for topical treatment of onychomycosis. Despite the limited sample size of this phase
2b, a trend of superiority versus vehicle was evident. Statistical significance would
have been achieved 3 months after end of treatment, slightly increasing the sample
size from 92 to 123 per treatment group.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P8513
P8715
Azathioprine: A therapy to be considered in alopecia universalis
Sivanie Vivehanantha, MBBS, Birmingham Skin Centre, Birmingham, United
Kingdom; Shireen Velangi, MBBS, Birmingham Skin Centre, Birmingham, United
Kingdom
Differential diagnosis of trichotillomania by trichoscopy
Adriana Rakowska, MD, PhD, Department of Dermatology CSK MSW, Warsaw,
Poland; Lidia Rudnicka, MD, PhD, Specjalisci Dermatolodzy, Warszawa, Poland;
Malgorzata Olszewska, MD, PhD, Department of Dermatology Medical University
of Warsaw, Warsaw, Poland
Alopecia areata (AA) is a T lymphocyteemediated autoimmune disorder of the hair
follicle. It is characterized by patchy hair loss developing in otherwise normal skin,
with ‘‘exclamation mark’’ hairs around margins of expanding areas. Most cases are
limited to 1 or more patches of hair loss, but in severe cases there may be complete
loss of hair on the scalp (alopecia totalis, AT) or on all hair-bearing sites (alopecia
universalis, AU). Treatment is not mandatory because the condition is benign and
spontaneous remissions and relapses are common. However, the condition often
results in significant psychological morbidity, thereby justifying treatment. Patients
with AT or AU usually have a poorer prognosis and pose a further therapeutic
challenge. We report a case of AU responsive to azathioprine on 2 separate
occasions. A 36-year-old woman with lifelong severe atopic eczema started to
develop AA as a teenager. From the age of 29, the AA rapidly worsened and within a
year it progressed to AU. In 2007 at the age of 29, she was commenced on oral
cyclosporine (stopped after a month because of side effects) and although her
eczema responded to treatment, the alopecia continued to progress. In February
2008, she was commenced on oral azathioprine for her eczema which responded
well, and within 6 weeks there was rapid hair regrowth and almost complete
regrowth within 8 months. In 2010, azathioprine was stopped as it had lost its
efficacy in controlling the severity of her eczema. Oral methotrexate was started in
June 2010 and although there was variable control of her eczema, the alopecia
relapsed. Methotrexate was stopped in April 2013 as the eczema was poorly
controlled. Azathioprine was recommenced in May 2013, again with a good
response of both her eczema and AU. There are numerous treatment modalities
for AA suggested in the literature: intralesional, topical, and systemic corticosteroids, topical immunotherapy, topical irritants, topical minoxidil, topical prostaglandin analogue, PUVA, oral immunosuppression, cryotherapy, and excimer lasers.
However, there are just 2 reports of the use of azathioprine in the treatment of AA in
the literature; 1 case report of AT and 1 small pilot study involving patients with AA
and AT. To the best of our knowledge, this is the first report of AU responding to
azathioprine. The rapid regrowth on commencement of azathioprine on the 2
separate occasions makes it unlikely that the response is purely related to chance.
The differential diagnosis between trichotillomania and other causes of hair may be
difficult in dermatologic practice. Trichoscopy (hair and scalp dermoscopy)
effectively supports differential diagnosis of various hair and scalp diseases. The
aim of this study was to analyze the usefulness of trichoscopy in differential
diagnosis of trichotillomania. Trichoscopy was performed in 370 patients (44 with
trichotillomania, 314 with alopecia areata, and 12 with tinea capitis). Statistical
analysis revealed that the main and most characteristic trichoscopic findings of
trichotillomania are: irregularly broken hairs (44/44; 100% of patients), v-sign
(24/44; 57%), flame hairs (11/44; 25%), hair powder (7/44; 16%), and coiled hairs
(17/44; 39%). Flame hairs, v-sign, and hair powder were not observed in other types
of hair loss. In conclusion, flame hairs, v-sign, and hair powder are specific
trichoscopy features, which may aid quick, noninvasive, in-office differential
diagnosis of trichotillomania.
Commercial support: None identified.
Commercial support: None identified.
P8074
Cortexolone 17a-propionate: A new antiandrogen acting on hair dermal
papilla cells for the treatment of androgenic alopecia
Giuseppe Celasco, MD, Cosmo Research and Development, SpA, Lainate-Milano,
Italy; Angela Milasi, PhD, Cosmo Research and Development, SpA, Catania
Laboratory, Catania, Italy; Daniel Piacquadio, MD, Therapeutics Inc, San Diego,
CA, United States; Luigi Moro, PhD, Cosmo Research and Development, SpA,
Lainate-Milano, Italy; Robert Gauthier, Therapeutics Inc, San Diego, CA, United
States
Background: The negative effects (miniaturization, shortening the anagen phase) of
dihydrotestosterone (DHT) on hair dermal papilla cells (DPCs) are well recognized.
As a consequence, substances endowed with antiandrogenic properties are
regarded as potentially useful in counteracting the hair growth effects of DHT. In
this study we evaluated the ability of 2 antiandrogens (cortexolone 17a-propionate
[CB-03-01] and cyproterone acetate [CA]) to antagonize in vitro the negative effects
of DHT on proliferation of DPC of mice expressing androgen-dependent baldness
(AGA-mouse).
Methods: DPCs were obtained from the dorsal skin of male B6CBAF1/J mice (Charles
River, Italy) just sacrificed. Isolated DPCs were incubated for 48 hrs with DHT alone
(0.5-5 M) or with the associations of DHT+CB-03-01 or DHT+CA at equimolar
concentrations (2.5 M). At the end of the incubation period the DPCs were labelled
with 5-bromodeoxyuridine, the label was detected by ELISA, and the proliferation
index was quantified using the photometry absorbance method.
Results: DHT incubated alone induced evident dose-dependent inhibition of DPC
proliferation up to -32.8% (P \.001). When CB-03-01 was incubated together with
DHT, the proliferation index was only minimally reduced (-2.4%), so that CB-03-01
almost completely abolished the inhibitory effect of DHT on DPC proliferation (P ¼
.007 vs. DHT). When CA and DHT were incubated together, the proliferation index
was reduced by -24.2%, not significantly different (P ¼ .210) from that induced by
DHT alone. The protective effect of CB-03-01 on DPC was ;103 higher than that
induced by CA. The reason CA, in spite of its well recognized antiandrogenic activity,
yielded poorly effective results is not understood. It is possible that the additional
endocrine properties of CA, such as its intrinsic progestinic activity, could interfere
with the effects at DPC level.
Conclusions: CB-03-01 represents a potent antagonist of DHT at the DPC level,
notably more effective than CA. Because of this mechanism of action, CB-03-01
should be regarded as an antiandrogen potentially useful for use in the topical
treatment of androgenic alopecia.
Support provided by Cosmo Research and Development, SpA and Intrepid
Therapeutics Inc.
P7924
Diphencyprone in the treatment of Satoyoshi syndrome
Nayra Merino de Paz, MD, Hospital Quir
on Tenerife, Santa Cruz de Tenerife,
Spain; Francisco Guimera Martin-Neda, MD, PhD, CHUC, La Laguna, Spain;
Marina Rodriguez Martin, MD, PhD, Hospital Quir
on Tenerife, Santa Cruz de
Tenerife, Spain; Miguel Saez Rodriguez, MD, Centro Madre, Santa Cruz de
Tenerife, Spain; Monica Merino de Paz, NP, CHUC, La Laguna, Spain; Patricia
Contreras Ferrer, MD, Hospital Quiron Tenerife, Santa Cruz de Tenerife, Spain;
Ruth Pitti Perez, MD, HUNSC, Santa Cruz de Tenerife, Spain
Introduction: Satoyoshi syndrome is a rare syndrome that it is characterized by the
presence of alopecia, diarrhea, muscular spasms, osseous abnormalities, and
endocrinopathies. About 52 cases have been described in the literature. Oral
glucocorticoids, azathioprine, tacrolimus, methotrexate, and intravenous immunoglobulins have been described as useful treatments in this syndrome.
Case report: This report describes a 12-year-old girl with universal hair loss from
scalp, eyebrows, and eyelashes since 7 years ago. She also presented with painful
intermittent muscle spasms and growth retardation with metaphyseal and epiphyseal dystrophy. Carbamazepine and otilonium bromide treatment led to the
disappearance of her muscles spasms and diarrhea, and she is currently being
treated with growth hormone. Several systemic treatments were attempted without
improvement 7 years ago, with several adverse events and quality of life affectation.
We decided to use safety therapies for the alopecia. Intermittent oral glucocorticoid
therapy (30 mg once a week) was attempted for a month, but a lot of adverse events
appeared, especially very disturbing diarrhea. Topical glucocorticoids after 4
months did not induce hair regrowth. UVB phototherapy induced a hard headache.
We started topical diphencyprone once a week with a good response and without
adverse events.
Discussion: Dyphencyprone is one of the options to treat alopecia areata. It is a
topically administered drug that induces a local immune response. In the literature,
Satoyoshi syndrome has been treated by oral glucocorticoids, with good results for
spasms, alopecia, and diarrhea. Intravenous immunoglobulins have improved
spasms and decreased anti-DNA antibodies. Few patients have been treated with
azathioprine, methotrexate and tacrolimus with good response. But all of these
treatments have a lot of adverse effects and risks, as immunosuppression.
Conclusion: This is the first report of diphencyprone therapy of alopecia associated
with Satoyoshi syndrome.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB89
P8593
P8227
Direct hair growth promoting effects of mycophenolic acid
Hoon Kang, MD, PhD, Department of Dermatology, St. Paul’s Hospital, College of
Medicine, The Catholic University of Korea, Seoul, South Korea; Jung Eun Kim,
Department of Dermatology, St. Paul’s Hospital, College of Medicine, The
Catholic Unviersity of Korea, Seoul, South Korea; Kwanho Jeong, Department
of Dermatology, St. Paul’s Hospital, College of Medicine, The Catholic Unviersity
of Korea, Seoul, South Korea; Young Min Park, MD, PhD, Department of
Dermatology, St. Paul’s Hospital, College of Medicine, The Catholic Unviersity
of Korea, Seoul, South Korea
Frontal fibrosing alopecia and lichen planus pigmentosus
Jacqueline Berliner, MD, UCSF Department of Dermatology, San Francisco, CA,
United States; Timothy Berger, MD, UCSF Department of Dermatology, San
Francisco, CA, United States; Vera Price, MD, UCSF Department of Dermatology,
San Francisco, CA, United States
Mycophenolic acid (MPA) acts as a cell cycle inhibitor that produces reversible
noncompetitive blockade of the purine synthesis pathway enzyme type II isoform of
inosine monophosphate dehydrogenase (IMPDH). The major target of MPA is
lymphocyte which contains abundant IMPDH. Among several kinds of hair loss
disorders, lymphocytic cicatricial alopecia and alopecia areata are most representative hair loss conditions induced by T lymphocyte attack to the hair follicle.
Recently, in vitro study demonstrated that MPA effects on cellular proliferation and
upregulates some valuable gene expression. Although MPA pharmacokinetic
properties on purine synthesis pathway are well defined, the direct effects of
MPA on hair follicles have yet to be studied. Therefore, we performed to determine
the MPA either have a direct effect in vitro. In addition, we performed to determine
how the effect of microneedle directly around the hair follicle. In our preliminary
experiments, animal studies showed that topical mycophenolic acid treatment
shortens the telogen and cause resting hair follicles entering into the anagen.
However, effect of mycophenolic acid has not been fully demonstrated. In this study,
we found that human DPCs respond to MPA as examined by hair growth factors
responsive RT-PCR assay. We also found that mycophenolic acid treatment increases
the phosphorylation of ERK1/2 and b-catenin. We also found that direct b-catenin
pathway targets, such as Axin2 and Lef-1, are up-regulated by mycophenolic acid.
These data suggest activation of b-catenin pathway by mycophenolic acid. These
results suggest that be particularly important to develop new therapeutic option for
hair loss.
Commercial support: None identified.
Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia
predominantly affecting the frontal hairline and eyebrows. FFA shares common
histopathologic features with other lymphocyte-mediated cicatricial alopecias, such
as lichen planopilaris (LPP), central centrifugal alopecia, and pseudopelade (Brocq),
which are distinguished clinically. LPP has been associated with mucocutaneous
lichen planus; however, the patterns of lichen planus associated with other
lymphocyte-mediated cicatricial alopecias are less well established. We report 2
Hispanic women with FFA and lichen planus pigmentosus (LPPigm), adding to the
recent literature on patients with these coexistent conditions. Both women
experienced perimenopausal onset of progressive gray-brown macules on the
face and neck in a photodistribution. Patient 1 secondarily complained of
frontotemporal hair loss. Patient 2 had complete eyebrow loss, but was not aware
of the subtle frontotemporal recession observed on examination. The development
of LPPigm preceded the onset of FFA in both cases. Biopsy from the temple of
patient 1 revealed atrophic vacuolar interface reaction with postinflammatory
pigmentary alteration, consistent with atrophic lichen planus actinicus. For Patient
2, biopsy from the neck revealed atrophic lichenoid interface reaction and another
from the frontal scalp revealed lymphocyte-mediated cicatricial alopecia. The
association of LPPigm with FFA further supports a shared underlying mechanism
between lichen planus and the primary lymphocytic alopecias. It has been
suggested to look for clinical and histopathologic evidence of FFA in patients with
LPPigm. Early recognition of FFA is important to allow for medical intervention to
hopefully slow if not prevent progression. Toward this end, it is also important to
differentiate LPPigm from conditions with which it is often confused, especially
erythema dyschromicum perstans (EDP). EDP, a rare condition, has not been
associated with FFA. The role of ethnicity in lichen planus and primary lymphocytic
cicatricial alopecias needs to be further elucidated. LPPigm has been documented
predominantly in dark-skinned patients. We hypothesize that in patients with FFA,
the variant of lichen planus that is associated, is that which is most commonly seen
in their given ethnicity. We recommend noting ethnicity in future studies of lichen
planus and its various expressions, and in studies of the primary lymphocytic
cicatricial alopecias.
Commercial support: None identified.
P7774
P7712
Enabling finasteride 1 mg users to further improve hair pattern: A
randomized, double-blind, placebo-controlled trial of a novel product
Akira Takeda, MD, PhD, Kitasato University School of Medicine, Sagamihara,
Japan; Akio Sato, MD, PhD, Tokyo Memorial Clinic, Tokyo, Japan; Geert
Cauwenbergh, PhD, Legacy Healthcare, Epalinges, Switzerland; JiaWei Liu,
PhD, Legacy Healthcare, Epalinges, Switzerland; Lei Zhang, PhD, Legacy
Healthcare, Epalinges, Switzerland; Saad Harti, MBA, Legacy Healthcare,
Epalinges, Switzerland
Background: The efficacy of finasteride 1 mg, the first-line treatment for male
androgenetic alopecia (AGA), tends to reach a plateau after several years’ treatment.
Up to date, effective and safe options are limited because current modalities
managing AGA have so far not taken into account the 2 key issues particularly
relevant to excessive hair loss: the early onset of catagen (due to premature hair
follicular cell apoptosis) and the frequently observed sustained microinflammation
in the scalp.
Objective: We investigated the potential synergic effect of combining the oral
finasteride 1 mg, acting on conversion of testosterone to 5a-dihydrotestosterone,
with a novel topical antiehair loss product, acting on premature apoptosis and
microinflammation in the scalp.
Methods: We designed a 12-month, randomized, double-blind, placebo-controlled
trial in 20 AGA volunteers already using finasteride 1 mg for at least 3 years. Hair
diameters were assessed and compared for hair pattern improvement.
Results: The increase of hair diameter in the finasteride 1 mg + novel product group
was 37.7% more than that in finasteride 1 mg + placebo group (P ¼ .002). No side
effects were observed.
Conclusion: Our results showed that in addition to 5-a reductase inhibitors,
simultaneously addressing both premature cell apoptosis in the hair follicles and
microinflammation in the scalp turned out to be an efficient approach in the
management of AGA with improved efficacy over the currently referenced modality.
In addition, the studied topical product may represent a new option for alopecia
subjects, including those under finasteride 1 mg, to improve their hair pattern.
Sponsored by Legacy Healthcare.
AB90
Frontal fibrosing alopecia: A multicenter review of 355 patients
Sergio Vano-Galvan, MD, PhD, Ramon y Cajal Hospital, Madrid, Spain; Ana
Molina, MD, Fundaci
on Jimenez Diaz, Madrid, Spain; Antonio Martorell, MD,
Hospital de Manises, Valencia, Spain; Francisco Camacho, MD, PhD, Hospital
Virgen Macarena, Sevilla, Spain; Pedro Jaen, MD, PhD, Hospital Ram
on y Cajal,
Madrid, Spain; Salvador Arias-Santiago, MD, PhD, Hospital de Baza, Granada,
Spain
Background: Frontal fibrosing alopecia (FFA) is a rare type of scarring hair loss
primarily observed in postmenopausal women. The incidence is unknown, but the
number of women presenting with this condition has significantly increased in
recent years. There are no large multicenter studies about frontal fibrosing alopecia
(FFA) that could give clues about its pathogenesis and best treatment.
Objective: To describe the epidemiology, comorbidities, clinical aspects, diagnostic
findings, and therapeutic choices in a large series of patients diagnosed of FFA.
Methods: A retrospective multicenter study was designed including patients
diagnosed with FFA. Clinical severity of FFA was classified based on the recession
of the frontal and temporal hairline. Response to therapy was assessed as worsening
(progression of hairline recession), stabilization (arrest of hairline recession), or
improvement (any regrowth of hair in the hairline).
Results: A total of 355 patients (343 females, 55 premenopausal, and 12 males) with
a mean age of 61 years (range, 23-86) were included in the study. Early menopause
(45 years) was detected in 49 patients (14%), with a surgical cause in 31 of them
(9%). Forty-six patients (13%) underwent hysterectomy. Severe FFA was observed in
131 patients (37%). The independent factors associated with severe FFA after
multivariant analysis were: eyelashes loss (OR, 5.41; P ¼ .020), corporal hair
involvement (OR, 5.24; P ¼.22), and the presence of facial papules (OR, 4.48; P ¼
.034). Finasteride was used in 102 patients, with improvement in 48 (47%) and
stabilization in 54 (53%). Dutasteride was used in 18 patients, with improvement in
8 (44%) and stabilization in 10 (56%).
Conclusions: Frontal fibrosing alopecia is a type of cicatricial alopecia that usually
affects postmenopausal women. However, this entity may appear in premenopausal
women or in men. Interestingly, we found a high rate of women with FFA presenting
early menopause or with hysterectomy, emphasizing the hormonal pathogenesis of
FFA. Treatment with oral antiandrogens and intralesional steroids may be useful.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P8628
P8730
Identification of onychomycosis infectious agents: Are PCR and culture
results consistent with each other?
Aditya Gupta, MD, PhD, University of Toronto, London, Canada; Kerry-Ann
Nakrieko, PhD, Mediprobe Research, London, Canada
Pivotal phase III safety and efficacy results of tavaborole (AN2690), a novel
boron-based molecule for the topical treatment of toenail onychomycosis
Boni Elewski, MD, Department of Dermatology, University of Alabama,
Birmingham, AL, United States; Lee Zane, MD, Anacor Pharmaceuticals, Inc,
Palo Alto, CA, United States; Phoebe Rich, MD, Oregon Dermatology and
Research Center, Portland, OR, United States; Raza Aly, PhD, Department of
Dermatology, University of California, San Francisco, CA, United States; Remigio
Gonzalez Soto, MD, Centro de Dermatologia de Monterrey, Monterrey, Nuevo
Leon, Mexico
Background: Mycologic culture is the traditional method to identify infectious
species; however, it can result in a high false negative rate. Recently, PCR, a
molecular biology technique, emerged as a tool for species identification from fungal
DNA. Yet, this method also has its drawbacks, such as possible identification of
nonviable fungi.
Objective: To quantify the magnitude of agreement in species identification
between culture and PCR.
Methods: Toenail specimens from 149 patients with suspected onychomycosis were
processed by mycological culture and PCR analysis. Sixteen dermatophytes and 5
nondermatophytes molds (NDMs) could be identified. Agreement between the 2
methods was quantified using the kappa statistic.
Results: PCR identified a larger number of samples positive for dermatophytes
(63/149 ¼ 42%) compared to culture (26/149 ¼ 17%). The 2 methods identified the
same species in only 17% of the samples (23 Trichophyton rubrum and 3
Trichophyton mentagrophytes). Thirty-nine samples (26%) had positive results by
PCR only, whereas 2 samples (1%) had positive results by culture only.
Consequently, a fair agreement was observed for identification of dermatophytes
by culture and PCR (r ¼ 0.415, P \.0001). For NDMs, most of the samples (126/149
¼ 85%) had negative results for both methods. Positive results were obtained for 16
(11%) samples by PCR and 6 (4%) samples by culture. The results between the 2
techniques were generally inconsistent. Similar positive results were obtained only
for 3 samples (1 Acremonium spp., 1 Scopulariopsis brevicaulis, 1 Fusarium
oxysporum by PCR or Fusarium spp. by culture). PCR identified NDMs in 17 culturenegative samples (5 S brevicaulis, 9 F oxysporum, 2 Syctalidium spp., and 1 S
brevicaulis + F oxysporum), whereas culture identified NDMs in 7 PCR-negative
samples (1 Acremonium spp., 2 F oxysporum, 3 Aspergillus spp., and 1 S brevicaulis
+ Acremonium spp.). One sample was identified as S brevicaulis by culture and as
mixed infection with S brevicaulis, F oxysporum, and Acremonium spp. by PCR.
The resulting Kappa score showed poor agreement between the 2 techniques for
the identification of NDMs (fl ¼ 0.173, P \.0001).
Conclusion: The PCR technique identifies infectious species in more samples than
the traditional culture technique. The agreement between the 2 methods is lacking,
especially for NDMs. Therefore, analysis of repeat serial samples is strongly
recommended for NDMs.
Commercial support: None identified.
Purpose: To determine the efficacy and safety of tavaborole topical solution, 5%
applied once daily versus vehicle for topical treatment of toenail onychomycosis.
Methods: Two pivotal, double-blind, randomized, vehicle-controlled, phase III trials
enrolled subjects aged ¼ 18 years with distal subungual onychomycosis involving
20% to 60% of the target great toenail. Study 301 enrolled 594 subjects in the US and
Mexico; study 302 enrolled 604 subjects in the US and Canada. Subjects were
randomized 2:1 to apply tavaborole topical solution, 5% or vehicle solution once
daily for 48 weeks. Nail debridement was not allowed. Primary and secondary
endpoints were assessed at week 52. The primary endpoint of complete cure was
defined as completely clear nail (no clinical evidence of onychomycosis) and
negative mycology (negative KOH and fungal culture). Secondary endpoints
included completely clear or almost clear nail, defined as ¼ 10% clinical
involvement; negative mycology; and completely clear or almost clear nail with
negative mycology. Safety assessments included adverse events (AEs), local
tolerability, laboratory tests, physical examinations, vital signs, and
electrocardiograms.
Results: Tavaborole topical treatment met all primary and secondary endpoints at
P ¼.001. For tavaborole vs vehicle, respectively, the complete cure rates were 6.5%
vs 0.5% in study 301 (P ¼.001) and 9.1% vs 1.5% in study 302 (P \.001). Negative
mycology was obtained in 31.1% of subjects treated with tavaborole vs 7.2% of
vehicle-treated subjects in study 301 and in 35.9% vs 12.2% of subjects in sStudy 302
(P\.001 for both). In both studies, the proportion of subjects with completely clear
or almost clear nail was superior with tavaborole (26.1% vs 9.3% in study 301; 27.5%
vs 14.6% in study 302 [P \.0001 for both]). A superior outcome was also observed
for completely clear or almost clear nail with negative mycology with tavaborole
treatment (15.3% vs 1.5% in study 301; 17.9% vs 3.9% for study 302 [P \.001 for
both]). In both phase III trials, tavaborole topical solution, 5% was well tolerated: no
serious AEs related to the study drug were reported and a low rate of discontinuation
as a result of AEs was observed.
Conclusion: Based on these phase III data, tavaborole topical solution, 5% applied
once daily appears to be a safe and effective treatment for toenail onychomycosis.
Sponsored 100% by Anacor Pharmaceuticals, Inc.
P8643
Management of onychomycosis in North America in 2014
Aditya Gupta, MD, PhD, University of Toronto, London, Canada; Maryse Paquet,
PhD, Mediprobe Research, London, Canada
Background: Onychomycosis has several clinical presentations and is caused by a
variety of infectious organisms. Yet the efficacy and safety of antifungals is often
investigated in the most prevalent type of onychomycosis, distal lateral subungual
onychomycosis caused by dermatophytes, in otherwise healthy adults. Therefore,
clinicians may not always be aware of the optimal antifungal therapy for a specific
presentation or a special population.
Objective: To provide guidance for the selection of the most appropriate treatment
for the management of onychomycosis.
P8357
Methods: The published literature on the management of onychomycosis in general
and special populations was reviewed to generate an evidence-based decision tree.
Retronychia: A rarely diagnosed and often misinterpreted cause of
chronic paronychia
Min Wee Chia, MD, Changi General Hospital, Singapore, Singapore
Results and conclusion: Several antifungal options are available in North America:
(1) 3 systemic antifungals: terbinafine, itraconazole, and fluconazole (off-label), (2) 2
topicals: efinaconazole 10% nail solution (available soon) and ciclopirox 8% nail
lacquer combined with debridement, and (3) laser therapy. If there is presence of
dermatophytoma, nail debridement or avulsion combined with topicals/orals is
recommended. Otherwise, the therapy selection depends on the infectious
organisms. Onychomycosis caused by nondermatophyte molds can be managed
with terbinafine combined with topicals. For Candida infection, itraconazole,
fluconazole, efinaconazole, or laser therapy can be used if the patient does not
take any concomitant medication. If the patient is taking concomitant medications,
terbinafine would be the safer choice if systemic therapy is required. For mixed
infections with dermatophytes, terbinafine combined with topicals is recommended. For dermatophytes only, topicals or lasers can be considered if \50% of the nail
area is affected, there is no matrix involvement and \3 digits are affected. For more
severe cases, any systemic monotherapy or in combination with topicals can be
used; however, we suggest using terbinafine if there is a chance of drug interaction
with concomitant medication. Based on the current evidence, these recommendations can be applied independently of the age of the patients, their immune
function, and metabolic status. Importantly, itraconazole therapy is contraindicated
in patients with history of congestive heart failure and fluconazole should be
monitored in patients with renal dysfunction.
Ingrown nails affect predominantly the toenails and virtually always result from the
embedding of lateral nail spicules into the lateral nail folds. In contrast, retronychia
involves proximal ingrowth of the nail that occurs when the nail embeds backwards
into the proximal nail fold. This condition was first described in 1999. Since then,
fewer than 40 cases have been cited in the literature. We present a case of
retronychia in a 24-year-old female professional dancer. She presented with a 3month history of stunted nail growth and painful swelling of her left big toe that did
not respond to topical steroids and systemic antibiotics. Her symptoms were
precipitated by dancing and wearing tight dance shoes. On examination, the left
great toenail exhibited yellowish discoloration, distal onycholysis, and marked
swelling with erythema of the proximal nail fold. A diagnosis of retronychia was
made based on her history of recurrent trauma and clinical signs of proximal nail
thickening and exuberant proximal paronychia with granulation tissue under the
proximal nail fold. She underwent nail avulsion using the proximal approach. After
avulsion, she recovered well, and no recurrence occurred. Retronychia usually does
not recur. Once treated with avulsion, it generally resolves without complications.
The avulsed nail plate also aids in the diagnosis by its proximal thickening, often
showing two or more layers when viewed proximally. Retronychia is a recently
described nail disorder whereby proximal ingrowth of the nail occurs when the nail
embeds backwards into the proximal nail fold. Unless it is recognized, it can be
misinterpreted and inadequately treated.
Commercial support: None identified.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB91
P8633
P7547
Robotically assisted follicular unit extraction in surgical hair restoration
Aditya Gupta, MD, PhD, University of Toronto, London, Canada; Danika Lyons,
MS, Mediprobe Research, London, Canada
Thousands of surgical hair restoration procedures are performed across the world
every year. Transplantation of individual follicular units (FU) from the donor region
to the recipient region is considered the criterion standard in terms of creating
natural looking hair restorations. The 2 most common procedures used to extract
FUs from the donor region are strip/linear extraction and manual follicular unit
extraction (FUE). Both of these methods provide natural looking hair transplantations and hold their own individual merits; however, both methods are also
associated with their own limitations. The introduction of robotic surgical assistive
devices that operate under the supervision of a physician may circumvent many of
the limitations associated with the traditional strip/linear and FUE extraction
methods. FUE surgery performed with robotic-assistance offers a novel, effective,
timely, and relatively painless procedure for harvesting healthy FUs grafts with a low
transection rate directly from the donor site. Thus far, robotically assisted FUE
surgeries have demonstrated hair restoration outcomes comparable to that of
traditional manual FUE; however, additional independent scientific evaluation is
required before a final determination of efficacy and long-term results can be
established. At this time, robotic assistive FUE devices have FDA approval in the
United States and have a medical device license for use in Canada for use on men
with dark colored hair, although they are being successfully used in more diverse
populations including women and people ranging in hair colors, textures, and
densities. Overall, robotically assisted FUE appears to be an innovative means for
performing safe, effective, and replicable FUE procedures with low transection
rates, thereby ensuring full and natural looking hair growth on the recipient scalp.
Telogen effluvium and associated incidence of abnormal serum ferritin,
zinc, 25-hydroxy vitamin D, and thyroid-stimulating hormone
Amanda Champlain, MD, Northwestern University Feinberg School of Medicine,
Department of Dermatology, Chicago, IL, United States; Daniel Bach, MD,
Northwestern University Feinberg School of Medicine, Department of
Dermatology, Chicago, IL, United States; Dennis West, PhD, Northwestern
University Feinberg School of Medicine, Department of Dermatology, Chicago,
IL, United States; Heather Wickless, MD, Northwestern University Feinberg
School of Medicine, Department of Dermatology, Chicago, IL, United States;
Maria Colavincenzo, MD, Northwestern University Feinberg School of Medicine,
Department of Dermatology, Chicago, IL, United States; Trevor Jones, University
of Arizona College of Medicine, Tucson, AZ, United States
Introduction: Telogen effluvium (TE) is a diffuse, nonscarring alopecia after an
abrupt and predominant shift of hair follicles from anagen to telogen phase.
Proposed cofactors include, but are not limited to, endocrine and nutritional
abnormalities, drug reactions, and physical and psychological stress. In addition,
possible triggers that can be objectively measured include abnormalities of iron,
vitamin D, zinc, and thyroid hormone. The primary objective was to determine the
reported incidence of abnormal serum ferritin, zinc, 25-hydroxy vitamin D, thyroidstimulating hormone (TSH), and free thyroxine (fT4) in a population of patients with
TE, and to identify possible trigger events in this TE population.
Commercial support: None identified.
Conclusion: In our patient population, vitamin D deficiency was the most frequent
laboratory abnormality identified (43% of 79 tested patients). Psychological stressors
were the most common patient and/or physician-suspected triggering events, yet in
32% of patients, no triggering factor was identifiable. Recently, low vitamin D in a
controlled study has been associated with TE. Additional investigation is needed to
understand the mental and physical stressors that precipitate TE.
P8723
Safety and efficacy of tavaborole (AN2690), a novel boron-based molecule,
in 3 phase II trials for the topical treatment of toenail onychomycosis
Mirna Toledo Bahena, MD, Instituto Mexicano de Investigacion Clinica, Federal
District, Mexico; Jose Barba Gomez, MD, Instituto Dermatologico de Jalisco ‘‘Dr.
Jose Barba Rubio,’’ Jalicso, Mexico; Lee Zane, MD, Anacor Pharmaceuticals, Inc,
Palo Alto, CA, United States; Richard Pollak, DPM, MS, Endeavor Clinical Trials,
PA, San Antonio, TX, United States; Terry Jones, MD, J&S Studies, Inc, College
Station, TX, United States
Purpose: Three phase II trials were conducted to determine the safety and efficacy of
tavaborole topical solution for topical treatment of toenail onychomycosis.
Methods: The 3 phase II studies (200, 201, and 203) enrolled adults with distal
subungual onychomycosis involving 20% to 60% of the targeted great toenail. Study
200 was a double-blind, vehicle-controlled, dose-ranging trial; studies 201 and 203
were open-label. Across the 3 trials, vehicle or tavaborole solution at concentrations
of 1%, 2.5%, 5%, or 7.5% was topically administered for 180 or 360 days. Mycologic
assessments (KOH wet mounts and fungal cultures) and clinical assessments
(Investigator Static Global Assessment [ISGA] and clear nail growth) were
performed in all studies. For studies 200, 203, and for study 201 cohorts 1 and 2,
the primary endpoint was treatment response at day 180, defined as negative culture
$ 2 mm clear nail growth or ISGA score of clear or almost clear after 6 months. For
study 201 cohort 3, the primary endpoint was treatment response at day 360,
defined as clear nail plus negative fungal culture. Safety assessments included
collection of adverse events (AEs), application site reactions, laboratory tests,
physical examinations, and vital signs.
Results: The studies enrolled a total of 336 patients. In the studies with treatment
duration of 180 days, efficacy was observed across tavaborole concentrations of
2.5%, 5%, and 7.5%; the proportion of patients achieving a treatment response with
tavaborole of any concentration ranged from 26% to 53% across the 3 trials. In the
randomized, vehicle-controlled, dose-ranging study (study 200), all concentrations
of tavaborole (2.5%, 5.0%, or 7.5%) demonstrated superiority versus vehicle, with 5%
tavaborole showing the best balance between efficacy and safety at the day 360
follow-up. In most treatment cohorts, a negative mycology culture was obtained in
[90% of subjects within the first 2 weeks of treatment. In all 3 phase II trials,
tavaborole topical solution was well tolerated. Most AEs were mild and most were
considered not related to study drug. All 13 serious AEs were considered unrelated
to study drug. Application site reactions were generally mild and reversible.
Conclusion: In 3 phase II trials of adult patients with onychomycosis, tavaborole
topical solution showed a good safety profile as well as a therapeutic effect at all
concentrations tested; the 5% solution exhibited the best balance of efficacy and
tolerability.
Sponsored 100% by Anacor Pharmaceuticals, Inc.
AB92
Methods: A diagnostic code search was performed to identify patients clinically
diagnosed by a dermatologist as TE over a 24-month period in a large, urban, single
site, academic-based dermatology practice in Chicago. Data collected from medical
records included age, race, sex (all females), suspected hair loss trigger factor(s), and
serum ferritin, zinc, 25-hydroxy vitamin D, TSH, and fT4. Trigger events were
categorized as endocrine, nutritional, drug-related, physical, or psychological
stressors.
Results: Nintey-nine females with TE were included in our analysis. The incidence of
abnormal laboratory results was as follows: low serum ferritin 9/93 (9.7%), low
serum zinc 4/61 (6.6%), low serum 25-hydroxy vitamin D 34/79 (43%), low TSH
2/58 (3.4%), and high TSH 4/58 (6.9%). The proportions of patient and/or physician
suspected trigger factors were: endocrine 21/99 (21.2%), nutritional 15/99 (15.2%),
drug-related 7/99 (7.0%), physical stressor 7/99 (7.0%), and psychological stressor
31/99 (31.3%). Multiple triggering factors were suspected in 15/99 (15.2%) patients.
In 32/99 (32.3%) patients, no triggering factor was identifiable. There was no
statistically significant correlation between category of trigger factor and age, race,
or serology.
Commercial support: None identified.
P7666
The features of onychomatrimas on in vivo reflectance confocal
microscopy
Margaret Sanchez, MD, Department of Dermatology and Cutaneous Surgery,
Miller School of Medicine/University of Miami, Miami, FL, United States;
Antonella Tosti, MD, Department of Dermatology and Cutaneous Surgery,
Miller School of Medicine/University of Miami, Miami, FL, United States; Mariya
Miteva, MD, Department of Dermatology and Cutaneous Surgery, Miller School of
Medicine/University of Miami, Miami, FL, United States; Shasa Hu, MD,
Department of Dermatology and Cutaneous Surgery, Miller School of
Medicine/University of Miami, Miami, FL, United States
Onychomatricoma is a benign nail matrix tumor that often presents as yellow
onychodystrophy with overcurvature and splinter hemorrhages. The involved nail
plate characteristically shows multiple holes in the free edge. On histology, it is a
fibroepithelial nail matrix tumor infiltrating the nail plate, with multiple tunneled
cavities filled with serum and lined with matrix epithelium. RCM is a noninvasive
diagnostic tool with cellular resolution that correlates well with histology. RCM
VivaStack (Z-axis) mode can reach structures deeper than 300 m. RCM has been
extensively used to evaluate melanocytic lesions, with only a few reports on RCM in
nail assessment. There has not been any publication of using in vivo RCM in the
evaluation of onychomatricoma. We used RCM to assess 4 patients with onychomatricoma before surgical excision. We evaluated the affected nail and unaffected nail
of each patient with VivaScope 1500 (Lucid Inc, Rochester). VivaStack mode was
used to take series of images at increasing depths from the dorsal nail plate to the nail
bed. We noticed in all 4 patients that the lesional nail plates demonstrated
longitudinal dark areas and white/grey lines, forming channel structures within
the nail plate at a depth of 186 to 505 m. The channels were outlined by bright
circular lines with a grey dot in the center. The unaffected nails showed homogenous, white/grey structureless areas, corresponding to healthy nail plates. All 4
patients had surgical excision with histopathologic confirmation. We were able to
correlate the tunneled cavities found in histology with the channel structures
observed on RCM. The channels are dark, likely corresponding to serum and blood
which have low refraction of light on RCM. In addition, the matrix epithelium cells
outlining the cavities appeared as circular bright lines with dark dot in the center
(nuclei) on RCM. These RCM features seen in onychomatricoma can be easily
differentiated from onychomycosis (bright linear elements corresponding to the
hyphae). In conclusion, RCM evaluation of onychomatricomas prior to surgical
excision provided important RCMepathologic correlation, and can be used as a
noninvasive diagnostic tool for onychomatricomas.
Commercial support: None identified.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
P7886
P8040
The impact of hair care practices and attitudes toward hair management
on exercise habits in African American women
Christine Ahn, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Amy McMichael, MD, Wake Forest Baptist Health, Winston-Salem, NC,
United States; Phillip Smith, Wake Forest School of Medicine, Winston-Salem,
NC, United States
Introduction: Physical activity (PA) is a vital component of health maintenance and
preventive medicine. African American women represent a patient population with
lower rates of physical activity. Although the reasons for engaging in regular exercise
are multifactorial, potential contributing factors in this population are hair care
practices and the relationship between exercise and hair management.
TNF-a in nonscarring inflammatory alopecia
Anne Neeley, MD, Saint Louis University, Saint Louis, MO, United States; Claudia
Vidal, MD, PhD, Saint Louis University, Saint Louis, Missouri, United States
Background: Alopecia areata (AA) is an inflammatory, nonscarring alopecia thought
to have autoimmune etiology. T cells and numerous cytokines are involved in the
pathogenesis, including IFN-gamma, interleukins, and TNF-a play a role in the
pathogenesis. TNF-a levels in the skin have been positively correlated with both
plasma ACTH levels and cutaneous ACTH receptor expression under conditions of
repeated stress in humans, which is thought to be a precipitating factor in AA and
known to precipitate telogen effluvium. The underlying pathogenic link between
stress and telogen effluvium is widely accepted but not fully elucidated. Numerous
cytokines, hormones, and inflammatory cells play a role in the stress response.
Purpose: To characterize hair care practices in African American women and how
hair and scalp health affect patients’ perceptions and performance of PA.
Methods: A 70-item questionnaire was administered to all women participating in a
free community physical activity program in Forsyth County, NC. Inclusion criteria
were self-identified African American race, female sex, and age between 21-75 years.
Participants were asked about the types, frequency, and intensity of PA, and about
hair care, hair styles, and hair and scalp health.
Results: A total of 86 women were surveyed, and 61 (71%) completed the
questionnaire. The mean age of survey respondents was 52.3 years (range, 32-67).
Participants reported exercising an average of 3.1 days per week for 43 minutes per
day. The most commonly performed physical activities in a typical week were light
household chores (98%) and walking for exercise (84%). When asked about factors
preventing them from exercise, hair management was reported to be as prohibitive
to exercise as a lack of good health. Thirty-one percent reported that exercise
increased the amount of time spent managing their hair, and 18% exercised less than
they would like because of their hair. The main hair care practices or problems
identified were sweating out of hair style (18%) and time to wash, dry, and style their
hair (13%). During exercise, the most frequent methods used to preserve hair style
were pony tails (36%) and hair wraps (21%). More than half of respondents reported
doing nothing (53%). When asked about their health and weight, 53% of women had
known hypertension, and 20% had diabetes. Most women either considered
themselves to be overweight (74%) or had been told they were overweight by a
health professional (62%), and 77% of women were unhappy with their current
weight.
Conclusion: Hair care practices and hair and scalp health may contribute to African
American women’s perception of and attitudes toward exercise. This is a potential
area where dermatologists can provide guidance to patients and facilitate regular
exercise.
Objectives: Given previous research suggesting a potential link between TNF-a and
AA and the complex interplay of the stress response and cytokines involved in
telogen effluvium, TNF-a should be increased in biopsies of AA and telogen
effluvium.
Methods: Cases of telogen effluvium, AA, and androgenetic alopecia were selected
from our department’s dermatopathology database. Elliptical scalp excisions of
benign nevi were selected, and the tips of these excisions were used as a ‘‘normal
skin’’ controls. All specimens were stained with TNF-a using an established protocol.
Each slide was examined and evaluated for TNF-a staining positivity by a boardcertified dermatopathologist. The follicular epithelium, nerves, and blood vessels
were rated as positive or negative for TNF-a staining.
Results: Controls demonstrated the highest rate of positive TNFa staining of all
structures examined (follicle, vessels, and nerves). Compared to control, AA and TE
both had significantly less TNF-a staining of the outer root sheath. Cases of TE
showed the least staining of vessels, approaching statistical significance compared
to controls. There there was a significant difference between AA, TE and control
which contradicted our hypothesis. Our results could provide an explanation for
reported cases of patients developing AA while taking TNF-a inhibitors.
Commercial support: None identified.
Commercial support: None identified.
P7714
P8609
Topical botanical extract for management of chemotherapy-induced
alopecia
JiaWei Liu, PhD, Legacy Healthcare, Epalinges, Switzerland; Geert Cauwenbergh,
PhD, Legacy Healthcare, Epalinges, Switzerland; Lei Zhang, PhD, Legacy
Healthcare, Epalinges, Switzerland; Saad Harti, MBA, Legacy Healthcare,
Epalinges, Switzerland
Introduction: Chemotherapy-induced alopecia (CIA) is considered the most visible
and emotionally distressing side effect of cancer therapy. There are no approved
pharmacologic treatments available. During CIA, the rapidly dividing cells in anagen
phase of hair follicles are damaged by the systemic chemotoxic agents and undergo
premature apoptosis, inducing early onset of catagen. The intrinsic pathway of
apoptosis is essentially mitochondrial-dependent and executed by members of
antiapoptotic Bcl-2. That the proapoptotic protein p53edeficient mice model does
not develop CIA suggests apoptosis has an important effect in causing CIA. The
mechanism for CIA protection in that mice model is thought to be inhibition of hair
follicle apoptosis by downregulation of Fas and upregulation of Bcl-2. Therefore,
local inhibition of excessive apoptosis has been proposed to prevent chemoassociated hair loss. Early onset of catagen also serves as the major universal
downstream factor of androgenetic alopecia (AGA). Considering the complexity of
hair growth (cycling) and the sensitivity of cancer patients, AGA subjects could
potentially be recruited as CIA mimic for proof of concept study. We present our
study of a GMP-grade botanical product on AGA subjects assessing Bcl-2 levels
compared with nonalopecia subjects. The number of anagen and telogen hair before
and after product application was recorded by phototrychogram to evaluate
respective A/T ratio. The topical product may provide with a promising avenue to
manage CIA by normalizing the intracellular Bcl-2 level.
Therapies for onychomycosis: A systematic review and network
metaanalysis of mycologic cure
Aditya K. Gupta, MD, PhD, University of Toronto, London, Canada; Deanne
Daigle, MS, Mediprobe Research, London, Canada; Maryse Paquet, PhD,
Mediprobe Research, London, Canada
New therapies for onychomycosis continue to be developed, yet many treatments
have not been directly compared in randomized controlled trials. The objective of
the current study was to compare the rates of mycologic cure for 8 monotherapies
for onychomycosis using Bayesian network metaanalysis. A systematic review of the
literature on systemic and topical onychomycosis treatments published until March
25, 2013 was performed. Interrater agreement for trial quality was quantified using
the kappa statistic. Intention to treat (ITT) mycologic cure rates were combined in
random effects metaanalyses. Heterogeneity was assessed using the inconsistency
index (I2). The node-split and network analyses were performed using the Aggregate
Data Drug Information System (ADDIS; version 1.16.3). A total of 948 articles were
retrieved and 15 studies (20 trials) were included in the analyses. Interrater
agreement for trial quality was substantial (fl ¼ 0.76). No significant heterogeneity
was found between trials (P values ¼ 0.24-0.79). All I2 values were 0 except for the
comparison between ciclopirox and placebo (I2 ¼ 0.29). Terbinafine 250 mg was
significantly superior to all treatments except itraconazole 400 mg pulse therapy.
Fluconazole and the topicals efinaconazole, ciclopirox, terbinafine nail solution, and
amorolfine were significantly superior to placebo only. Although no statistically
significant differences were found among topical treatments, efinaconazole
demonstrated the highest rates of mycologic cure for this treatment modality.
Results from this novel analysis support the established superiority of terbinafine
250 mg among systemic therapies. Undoubtedly, with more consistently designed
RCTs, an increased sample size, and power, the ranking will be more robust.
Nonetheless, these results are a reflection of the best available evidence to date for
the treatment of onychomycosis.
Results: After the product application, A/T ratio was raised from 2.96 (day 1) to 4.30
(day 44), and remained at 4.35 all along the study (day 86). Fraction of Bcl-2+ cells in
AGA subjects before vs. after the product application significantly increased by 89%
(from 1.72 to 3.24; P ¼.001), but remained below the normal level of Bcl-2 (4.73).
No adverse events were reported.
Conclusion: The antiehair loss product can safely normalize the antiapoptotic Bcl-2
level and prevent premature apoptosis (catagen) in AGA subjects. It may be used as
topical management of alopecia in chemo- or radiotherapy treated patients, in a
dosage to be investigated.
Supported by Valeant Pharmaceuticals Inc.
This research work is sponsored by Legacy Healthcare.
Study design: Phototrichogram was used to determine A/T ratio in 19 AGA male
subjects before and after application of the product, at days 1, 44, and 86.
Assessment of Bcl-2+ cells was performed by immunohistochemistry in scalp
biopsy in 25 male nonalopecia and 15 AGA subjects.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
AB93
P8451
P7992
Treatment experience of hidradenitis suppurativa at Mayo Clinic
John Kohorst, Mayo Clinic, Rochester, MN, United States; Christian Baum, MD,
Mayo Clinic, Rochester, MN, United States; Clinton Hagen, Mayo Clinic,
Rochester, MN, United States; Mark Davis, MD, Mayo Clinic, Rochester,
Minnesota, United States
Twisted and rolled body hairs with multiple, large knots
Young Jee Kim, MD, Departments of Dermatology, Chonnam National University
Medical School, Gwangju, South Korea; Jee-Bum Lee, MD, PhD, Departments of
Dermatology, Chonnam National University Medical School, Gwangju, South
Korea; Sang Yub Kim, MD, Departments of Dermatology, Chonnam National
University Medical School, Gwangju, South Korea; Seung-Chul Lee, MD, PhD,
Departments of Dermatology, Chonnam National University Medical School,
Gwangju, South Korea
Kontting of scalp hair (trichonodosis) is a frequent, but the knotting of body hair is a
very rare finding. This disorder may occur as an acquired or inherited trait. We
present a hair disorder characterized by an unusual twisting and matting of body
hairs. A 26-year-old man complained of hair problem on the forearm and thigh since
4 months ago. No mechanical trauma or history could be found. Rolled and knotted
hairs were visible to the naked eye. To identify the hairs with twist and knotting, we
examined the hairs with using light microscopy and scanning electron microscopy
(SEM). Light microscopy examination confirmed the clinical impression of twisted
and rolled hairs on the body. On SEM examination, it was found that multiple hairs
with twist and knotting were originated from different hair follicles and rolled and
stuck together. In results, the twisted and rolled body hairs with multiple and large
knots in Asians may appear temporarily on specific body sites without any cause as a
minor variant of scalp hair matting or belting. To date, 4 papers with this body hair
disorder has been reported in the literature, but not in Asians.
Background: Outcomes of individual treatments on hidradenitis suppurativa have
been studied but treatment strategy and outcome has not been reported over time in
Olmstead County, MN.
Objective: We sought to determine the treatments most commonly prescribed and
effectiveness of all systemic and surgical treatments used in the Mayo Clinic
hidradenitis supurativa patient population over a 40-year period.
Methods: A retrospective chart review was performed for hidradenitis suppurativa
treatments in 376 episodes of 115 patients seen at the Mayo Clinic between 1968
and 2008 by a clinician. The outcome of treatment episodes was recorded based on
the clinician note in the 77 treatment episodes with a follow-up period over 30 days.
Results: Systemic antibiotics alone were proscribed most frequently in 70.0% of
episodes. Systemic antibiotics alone improved 39 cases (79.6%) with 13 cases
(26.5%) fully cleared. Surgical treatment alone improved all 5 cases (100%) with 4
cases (80%) fully cleared. Combination surgery and systemic antibiotic treatment
improved 5 cases (71.4%) with 2 cases (28.6%) fully cleared.
Limitations: Combination of treatments were used in many treatment episodes. As in
most retrospective studies, follow-up was variable and often absent. Treatment
outcome was interpreted from notes of many clinicians.
Commercial support: None identified.
Conclusion: Systemic antibiotics were the most frequently proscribed treatment
type in 115 patients over a 40-year period. Both systemic antibiotic and surgical
treatment are effective in disease management.
Commercial support: None identified.
P7980
Unilateral poliosis and deafness
Lidia Maro~
nas-Jimenez, Servicio Dermatologıa Hospital Universitario Doce de
Octubre, Madrid, Spain; Aurora Guerra-Tapia, Servicio Dermatologıa Hospital
Universitario Doce de Octubre, Madrid, Spain; Concepci
on Postigo-Llorente,
Servicio Dermatologıa Hospital Universitario Doce de Octubre, Madrid, Spain;
Francisco Vanaclocha-Sebastian, Servicio Dermatologıa Hospital Universitario
Doce de Octubre, Madrid, Spain; Jimena Sanz-Bueno, Servicio Dermatologıa
Hospital Universitario Doce de Octubre, Madrid, Spain; Marıa CastellanosGonzalez, Servicio Dermatologıa Hospital Universitario Doce de Octubre,
Madrid, Spain; Ver
onica Monsalvez, Servicio Dermatologıa Hospital
Universitario Doce de Octubre, Madrid, Spain
P7650
Treatment of ingrown nail with a special device composed of
shape-memory alloy
Se-Won Park, MD, Department of Dermatology, Samsung Medical Center, Seoul,
South Korea; Dong-Youn Lee, MD, PhD, Department of Dermatology, Samsung
Medical Center, Seoul, South Korea; Ji-Ho Park, MD, Department of Dermatology,
Samsung Medical Center, Seoul, South Korea; Jong-Hee Lee, MD, PhD,
Department of Dermatology, Samsung Medical Center, Seoul, South Korea; JooHeung Lee, MD, PhD, Department of Dermatology, Samsung Medical Center,
Seoul, South Korea; Jun-Mo Yang, MD, PhD, Department of Dermatology,
Samsung Medical Center, Seoul, South Korea
Background : Ingrown nail is a common nail problem resulting in pain and disability
in daily life. Recently, a new treatment modality for an ingrown nail that used a
device composed of shape-memory alloy, K-D, was reported.
Objective : To determine the efficacy, recurrence rate, and complications of K-D.
Methods: Between June 2010 and September 2012, 24 patients (31 nails) underwent
treatment of symptomatic ingrown nails with a K-D. Patients were evaluated at
pretreatment and during every visit.
Results: The mean age of the patients involved was 43.4 years. The mean
maintenance period was 41 days. The mean period of follow-up was 161 days.
The right first toenail was the most common site. Almost ingrown nails healed and
the nail deformity was corrected after the procedure. The majority of patients were
very satisfied. Among the 31 nails, 7 nails of ingrown nails recurred during follow-up
(22.6% recurrence rate). There were no side effects in most patients except loss of
nail in 1 patient.
Introduction: Poliosis refers to a patch of white hair caused by the loss of pigment
from a group of closely positioned hair follicles, usually in scalp but also in
eyebrows, eyelashes, or other sites. Although this condition is commonly seen in
healthy people, in some cases it may be a sign of an underlying medical disease.
Case report: A healthy 55-year-old man was admitted to our department with a [10year history of left-sided whitening of his eyebrow and eyelashes. He also had a
history of loss of vision in his left eye regarding to retinal vein thrombosis but
otherwise he denied another systemic symptoms. There was no family history of any
similar alterations. The clinical examination revealed a left-sided poliosis in the
eyebrows, eyelashes, nose hair, mustache, and beard with a 2-cm hairless plaque on
the mustache. The right side of the face was completely preserved. Laboratory
investigations found previously unknown autoimmune hypothyroidism and moderate hypertriglyceridemia. After reviewing medical literature, we decided to rule
out underlying eye and ear pathology so the patient was referred to an
ophthalmologist and otorhinolaryngologist. Funduscopy showed no consistent
findings but audiometry revealed a mild ipsilateral sensorineural deafness. Finally,
the diagnosis of Alezzandrini syndrome was made.
Conclusion: The management of ingrown nails with the K-D was an effective and
safe treatment method without nail deformity.
Discussion: Few entities are manifested with unilateral poliosis. Among those
typically presented with ipsilateral deafness is Alezzandrini syndrome, a very rare
entity of unknown etiology that was first described by Alezzandrini and Casala in
1959, reporting 4 cases. Since that time, only 2 more cases have been published
worldwide, and there are no well-defined diagnostic criteria. Nevertheless, all cases
described were adults with a progressive history of hemifacial poliosis or vitiligo and
variable grades of ipsilateral tapetoretinal degeneration or hearing loss. The main
differential diagnosis is Vogt-Koyanagi-Harada syndrome, a multisystem inflammatory disease characterised by bilateral depigmentation anomalies, chronic uveitis,
and central nervous system involvement (aseptic meningoencephalitis). This case
reinforces the importance of the dermatologist on the recognition of these rare
systemic diseases, because the skin is frequently the clinical clue that allows an early
diagnosis of potentially more serious underlying medical anomalies.
Commercial support: None identified.
Commercial support: None identified.
AB94
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9231_9237_proof 8 March 2014 3:13 pm
IMMUNODERMATOLOGY AND BLISTERING
DISORDERS
P8450
A case of localized facial dermatitis herpetiformis
Lauren Taglia, MD, PhD, Geisinger Medical Center, Danville, PA, United States;
Eric Hossler, MD, Geisinger Medical Center, Danville, PA, United States
Background: Dermatitis herpetiformis, Duhring disease, is a chronic pruritic disease
characterized by symmetrically grouped papulovesicles found most commonly on
the extensor surfaces and buttocks. There is a strong association with glutensensitive enteropathy. There have been rare reports of localized disease involving
the face.
Case report: A 50-year-old man presented with 2-year history of recurrent pruritic
rash involving the face, particularly on the forehead. The rash would come and go
without an identifiable trigger. On examination, he had an eruption of small red,
crusted papules and papulovesicles confined to the forehead. Lesional skin biopsy
revealed subepidermal blister with neutrophils and occasional eosinophils.
Subsequent perilesional biopsy demonstrated 3+ granular IgA staining along the
dermoepidermal junction with accentuation in the dermal papillae, and tissue
transglutaminase IgA antibody was elevated, consistent with a diagnosis of
dermatitis herpetiformis. Treatment options were discussed with patient and
decision was made to start topical dapsone (Aczone 5% gel) twice daily. At followup, our patient noted marked improvement in number of lesions and control of
symptoms.
Discussion: This case demonstrates an unusual variant of dermatitis herpetiformis
limited to the face. Definitive treatment includes a strict adherence to a gluten-free
diet. Traditional pharmacotherapy includes dapsone and sulfapyridine. To our
knowledge, this is the first report of topical dapsone for the treatment of localized
disease.
Conclusion: Localized facial dermatitis herpetiformis is a rarely reported condition.
However diagnosis of this condition should be suspected under the appropriate
clinical scenario. In addition, topical dapsone preparations may represent a novel
treatment method for cases of localized disease.
Commercial support: None identified.
P8153
Assessment of level of evidence for treatments of inheritable immunodeficiency disorders with dermatologic manifestations
Romi Bloom, Northwestern University Feinberg School of Medicine, Department
of Dermatology, Chicago, IL, United States; Amy Paller, MD, Northwestern
University Feinberg School of Medicine, Department of Dermatology, Chicago,
IL, United States; Dennis West, PhD, Northwestern University Feinberg School of
Medicine, Department of Dermatology, Chicago, IL, United States; Giuseppe
Micali, MD, University of Catania, Dermatology Clinic, Catania, Italy; Lawrence
Schachner, MD, University of Miami Miller School of Medicine, Department of
Dermatology and Cutaneous Surgery, Miami, FL, United States; Lori Asztalos, MD,
MS, Northwestern University Feinberg School of Medicine, Department of
Dermatology, Chicago, IL, United States
Background: Genomic sequencing and therapeutic approaches are rapidly
advancing, providing clinicians with vital clues to more accurate diagnoses and
potential targeted therapies for inherited immunodeficiency disorders (IID) with
dermatologic manifestations, but with relatively few published studies and a
perceived low level of evidence for proposed treatments.
Methods: A systematic PubMed search was conducted to identify treatments
reported to be used in management of the following IID for which level of evidence
(LOE) could be assessed using JAAD guidelines: chronic mucocutaneous candidiasis
(CMC), cartilage-hair hypoplasia syndrome (CHHS), severe combined immunodeficiency disorder (SCID), hypohidrotic ectodermal dysplasia with immunodeficiency
(HED-ID), ataxia-telangiectasia (AT), WiskotteAldrich syndrome (WAS), chronic
granulomatous disease (CGD), leukocyte adhesion deficiency (LAD), hyperimmunoglobulinemia E syndrome (HIES), silvery hair syndromes (SHS; ChediakeHigashi
and Griscelli), and antibody deficiency disorders (ADDs; X-linked agammaglobulinemia, common variable immunodeficiency disorder, and hyper-IgM syndrome).
Results: The LOE for 156 treatments were determined from 406 citations. When [1
citation was available for a given treatment, the multiple citations were grouped and
1 determination for highest LOE was recorded for that treatment. A majority (75.6%)
of the LOE assessments were level III for all IID combined. The number of citations
used to assess the LOE for the treatments related to CMC, CHHS, SCID, HED-ID, AT,
WAS, CGD, LAD, HIES, SHS, and ADDs were 41, 11, 34, 17, 18, 41, 72, 35, 24, 33, and
80, respectively. Notably, the only disorders that had at least 1 treatment at LOE level
I were CMC, CGD, and ADDs, while HEDID, HIES, and SHS had level III as the highest
assessed LOE for any given treatment.
Conclusion: Nearly three-fourths of the LOE for treatments associated with IID is
level III (nonexperimental descriptive studies). Understandably, higher LOE (randomized, controlled trials) have been relatively rarely published, perhaps because of
ethical and safety concerns in these populations. Nevertheless, the plight of patients
with these inheritable immunodeficiency disorders underscores the need for new
and novel targeted therapies and additional controlled trials to better establish a LOE
acceptable to practitioners and to provide a more optimized benefit to risk ratio for
therapeutic approaches.
Commercial support: None identified.
P8339
Childhood bullous pemphigoid treated with a combination of prednisone
and methotrexate: A case report
Ana Sofıa Ayala-Cortes, MD, Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’ UANL,
Monterrey, Mexico; Gloria Marıa Rosales-Solıs, MD, Hospital Universitario ‘‘Dr.
Jose E. Gonzalez’’ UANL, Monterrey, Mexico; Ivette Miranda-Maldonado, MD,
Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’ UANL, Monterrey, Mexico; Jorge
Ocampo-Candiani, MD, Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’ UANL,
Monterrey, Mexico; Oliverio Welsh-Lozano, MD, Hospital Universitario ‘‘Dr. Jose
E. Gonzalez’’ UANL, Monterrey, Mexico; Osvaldo Tomas Vazquez-Martınez, MD,
PhD, Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’ UANL, Monterrey, Mexico;
Sylvia Aide Martınez-Cabriales, MD, Hospital Universitario ‘‘Dr. Jose E. Gonzalez’’
UANL, Monterrey, Mexico
Childhood bullous pemphigoid (BP) is a rare acquired autoimmune disease
characterized by tense blisters arising in an erythematous or urticarial base often
accompanied of pruritus; diagnosis is made identifying the typical subepidermal
blister with eosinophils and it is confirmed with inmunofluorescence showing
linear deposits of IgG and C3 in the basal membrane. Its usual presentation is in the
elderly, but there have been reports affecting children. The treatment for severe BP
is prednisone and DDS. We present a 13-year-old boy with a 3-month history of
generalized wheals, tense blisters, and crusts involving mucous membranes, palms,
and soles; previously treated with 2 days of dapsone (DDS), which was suspended
because of angioedema; followed by an irregular course of prednisone for 2 weeks.
At the time of hospital admission, the dermatosis’ severity impaired the deambulation and his food intake. Skin biopsy and direct inmunofluorescence were
consistent with BP. After 1 week with prednisone 1 mg/kg per day (80 kg) he
remained without improvement, at this time 7.5 mg/week of methotrexate was
added to his therapy. One week after the first dose he noted improvement, but with
exacerbation of lesions when exposed to sunlight and heat. Methotrexate was
increased to 10 mg/week and prednisone was tapered to 0.9 mg/kg/day. The usual
BP treatment in children is prednisolone (1-2 mg/kg/day); other therapies are
erythromycin, sulfapyridine, and DDS. There are isolated reports of use of
immunosuppressive agents like mycophenolate mofetil, rituximab, omalizumab,
and IVIG. Methotrexate has been administrated in adult BP with weekly low doses,
starting at 2.5 mg/week, being effective in combination with topical or systemic
corticosteroids, improving [90% of the patients. The safety and efficacy reports of
methotrexate in infants come from its use in other dermatologic and rheumatologic
diseases: psoriasis, pemphigus, systemic lupus, dermatomyositis ,and scleroderma,
in a dose ranging from 0.2 to 3 mg/kg/week for up to 72 months. In this patient, DDS
was contraindicated because of the development of angioedema; in addition, the
scarce family economic resources limited treatment options to prednisone and
methotrexate. This combination induced progressive to total remission of lesions
after 4 weeks of treatment.
Commercial support: None identified.
P8665
Clinical, histopathologic, and molecular characterization of cutaneous
Waldenstrom macroglobulinemia: Report of 4 cases
Ana I. Velazquez, Mayo Clinic Graduate School, Rochester, MN, United States;
Michael J. Camilleri, MD, Mayo Clinic Department of Dermatology, Rochester,
MN, United States; Paul J. Kurtin, MD, Mayo Clinic Department of Laboratory
Medicine and Pathology, Rochester, MN, United States; Rahul N. Chavan, MD,
PhD, Mayo Clinic Department of Dermatology, Rochester, MN, United States
Waldenstrom macroglobulinemia (WM) is a rare lymphoproliferative disorder
characterized by monoclonal IgM in the serum secreted by malignant B-cells that
infiltrate the bone marrow and lymphoid tissues. Cutaneous manifestations of WM
are uncommon, with predominance of nonspecific findings related to hyperviscosity or cryoglobulinemia. Specific lesions, referred to as cutaneous macroglobulinosis, are caused by dermal infiltration of neoplastic of B-cells and monoclonal IgM
deposition. We present a series of 4 patients with different cutaneous manifestations
of WM. Case 1, a 62-year-old female with WM developed nonpalpable purpura on
bilateral forearms and intermittent hemorrhagic bullae on the volar aspects of
bilateral hands. Histopathologic and immunohistochemical analysis revealed PASpositive perivascular hyalinization and fibrosis in papillary and upper reticular
dermis, negative for Congo red stain and IgM. Case 2, a 68-year-old male with IgMkappa monoclonal gammopathy developed diffuse, palpable, purpuric papules and
thin plaques on the lower extremities. Biopsy revealed leukocytoclastic vasculitis
with strong IgM granular deposition within dermal blood vessel walls. Case 3, an 82year-old male with WM developed discrete itchy, raised, scaly erythematous plaques
over his thigh and shoulder. Biopsy of the lesions showed PAS-positive hyaline
globules in the dermis with predominance of CD138+ kappa-light chain plasma cells;
mass spectrometry (MS) confirmed IgM kappa-light chain deposition. Case 4, a 43year-old male with WM developed numerous dome-shaped bleeding papules in the
elbows, knees, and buttocks. Biopsy of the lesions revealed deposition of
amorphous hyalinized PAS-positive, Congo redenegative material in the dermis,
with extensive IgM kappa-light chain deposition on MS. We would like to highlight
the variations in the clinical and histopathologic findings of this uncommon entity.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:16 pm
AB95
P7672
P7592
Comparative analysis of the in situ interleukin 23/T-helper 17 lymphocyte
axis cytokine profile in IgA pemphigus, subcorneal pustular dermatosis,
and pustular psoriasis
Thais Helena Dias Signorelli, MD, Dermatology Department, School of Medicine,
S~ao Paulo University (FMUSP), S~ao Paulo, Brazil; Celina Wakisaka Maruta, MD,
Dermatology Department, School of Medicine, S~ao Paulo University (FMUSP),
S~ao Paulo, Brazil; Claudia Giuli Santi, MD, Dermatology Department, School of
Medicine, S~ao Paulo University (FMUSP), S~ao Paulo, Brazil; Mirian Nacagami
Sotto, MD, Dermatology Department, School of Medicine, S~ao Paulo University
(FMUSP), S~ao Paulo, Brazil; Natasha Favoretto Dias, MD, Dermatology
Department, School of Medicine, S~ao Paulo University (FMUSP), S~ao Paulo,
Brazil; Ricardo Romiti, MD, Dermatology Department, School of Medicine, S~ao
Paulo University (FMUSP), S~ao Paulo, Brazil; Valeria Aoki, MD, Dermatology
Department, School of Medicine, S~ao Paulo University (FMUSP), S~ao Paulo, Brazil
Danazol-induced StevenseJohnson syndrome in a patient with systemic
lupus erythematosus
Mark Koh, MBBS, KK Women’s & Children’s Hospital, Singapore, Singapore; WeiLiang Koh, MBBS, Changi General Hospital, Singapore, Singapore
Background: IgA pemphigus, subcorneal pustular dermatosis, and pustular psoriasis
are rare disorders characterized by waves of widespread sheets of sterile pustules
with clinical, histopathologic, and therapeutic similarities. The etiology of these
diseases is unknown, and there is considerable confusion about their nature and
pathophysiology.
Objective: To characterize the in situ expression of the interleukin 23/T-helper 17
cytokine profile of the above mentioned dermatoses, in order to identify possible
common immunopathogenic mechanisms.
Design: Twenty-seven patients followed at the Department of Dermatology,
University of S~ao Paulo Medical School were selected (IgA pemphigus:
n ¼ 9, subcorneal pustular dermatosis: n ¼ 6, pustular psoriasis: n ¼ 12).
Immunohistochemical analysis was performed in paraffin-embedded biopsies material of pustular lesions. The expression of interleukin-17 and interleukin-23 was
analyzed. Statistical nonparametric tests were performed.
Limitations: Although the applied technique displayed the in situ expression of
interleukin-17, the production of interleukin-17 by T-helper 17 lymphocytes could
not be precisely evaluated.
Results: A similar expression of evaluated interleukins was observed in the diseases
studied specimens.
Conclusion: The tissular response resulting from the analyzed interleukins
approaches strongly suggests a common immunopathogenic link IgA pemphigus
and pustular psoriasis. Therefore, our findings corroborate the similarities observed
in these diseases.
Case report: A 19-year-old Malay lady, with a 5-year history of systemic lupus
erythematosus, presented with 2 days of facial rashes and oral ulcers. Her long-term
medications included oral tacrolimus 2 mg/day and prednisolone 15 mg/day.
Significantly, she had been started on oral danazol 200 mg/day for autoimmune
haemolytic anemia 2 weeks before her current admission. On examination, there
were dusky purpuric macules, papules, and targetoid lesions seen over her
forehead, bilateral cheeks, neck, arms, and palms. Erosions were seen on her lips,
hard palate, and vulva. The conjunctiva was normal. Systemic examination was
otherwise unremarkable except for mild pallor. Punch biopsy showed a subepidermal blister with full thickness epidermal necrosis. Interface change was seen
adjacent to the blister, with basal vacuolar alteration, necrotic keratinocytes and
exocytosis of lymphocytes. Alcian blue stain was negative for dermal mucin. These
changes were consistent with StevenseJohnson syndrome (SJS). Direct immunofluorescence was negative. A diagnosis of danazol-induced SJS was made and the
culprit drug was discontinued. She was started on intravenous methylprednisolone
with resolution of the rash.
Discussion: Danazol is an attenuated androgen indicated for treating endometriosis,
fibrocystic breast disease, and hereditary angioedema. It has been used successfully
for the treatment of SLE-associated autoimmune hemolytic anemia. The incidence of
SJS has been shown to be higher in patients with collagenevascular disorders like
SLE. SJS-like SLE has also been reported to occur because of extensive epidermal
necrosis from the intense interface reaction. Although SJS has been listed as a rare
reaction in the product insert of danazol, a causal relation has not been confirmed
nor refuted. We believe that this is the first case report of danazol-induced SJS.
Commercial support: None identified.
Commercial support: None identified.
P8364
P7901
Cost-effective algorithm for the differentiation of IgG-mediated subepidermal autoimmune blistering dermatoses
Justyna Gornowicz-Porowska, Autoimmune Blistering Dermatoses Section,
Department of Dermatology, Poznan University of Medical Sciences, Poznan,
Poland; Marian Dmochowski, Autoimmune Blistering Dermatoses Section,
Department of Dermatology, Poznan University of Medical Sciences, Poznan,
Poland; Monika Bowszyc-Dmochowska, Cutaneous Histopathology and
Immunopathology Section, Department of Dermatology, Poznan University of
Medical Sciences, Poznan, Poland; Pawel Pietkiewicz, Autoimmune Blistering
Dermatoses Section, Department of Dermatology, Poznan University of Medical
Sciences, Poznan, Poland; Zygmunt Adamski, Department of Dermatology,
Poznan University of Medical Sciences, Poznan, Poland
Dermatitis herpetiformis associated to dermatomyositis
Silvia Mendez-Flores, MD, Instituto Nacional de Ciencias Medicas y Nutrici
on,
Mexico D.F., Mexico; Fatima Tinoco-Fragoso, MD, Instituto Nacional de Ciencias
Medicas y Nutrici
on, Mexico D.F., Mexico; Judith Dominguez-Cherith, MD,
Instituto Nacional de Ciencias Medicas y Nutrici
on, Mexico D.F., Mexico;
Marcela Saeb-Lima, MD, Instituto Nacional de Ciencias Medicas y Nutrici
on,
Mexico D.F., Mexico
Introduction: Dermatitits herpetiformis (DH) is an autoimmune bullous disease that
has been primarily related to celiac disease; however, it has also been associated
with other autoimmune diseases, in some few cases associated with an inflammatory myopathy. Herein, we report a case presenting with DH and dermatomyositis
simultaneously.
The IgG-mediated subepidermal autoimmune blistering dermatoses (GSABD) are
characterized by IgG autoantibodies against the dermoepidermal junction (DEJ)
proteins. The clinical presentations of GSABD are extremely broad. There are 8,191
mathematical combinations of 13 clinical varieties of bullous pemphigoid (BP)
proper alone. Moreover, several recent studies indicated BP230 BP as distinct from
BP180 BP. Currently, the classification of the principal GSABD is based upon the
clinical signs and the molecular characterization of targeted antigens. Still, with
contemporary imaging/biochemical/molecular techniques, GSABD patients with
autoimmunity to numerous autoantigens (ie, autoantigens characterizing not single
but several GSABD) can be identified. Therefore, from a biologic point of view, a
continuous spectrum of GSABD exists. Here, cost-effective, 4-step algorithm for
differentiation of GSABD: BP circle, mucous membrane pemphigoid, antilaminin
gamma1 pemphigoid and epidermolysis bullosa acquisita circle is proposed using
just clinical signs evaluation with an emphasis on involvement of mucous
membranes (first step), direct immunofluorescence (DIF) with pattern of
IgG4/IgG1 DEJ deposits evaluated according to Vodegel method (second step),
blister fluid BP180 ELISA, and when negative blister fluid BP230 ELISA (serum used
only when blister fluid is unavailable) (third step), salt-split skin DIF for IgG4/IgG1
deposits done only when results of previous 3 steps (performed each time)
necessitate doing it (fourth step). Despite the fact that numerous GSABD were
described and still newer ones are constantly being described BP180 BP is,
according to both literature data and our laboratory experience, by far the most
common GSABD. Still, cost-effective, 4-step algorithm for differentiation of GSABD
delineated here could be widely used in everyday clinical practice for facilitating
choice of disease-orientated management strategies.
Case report: A 62-year old man presented with symmetric proximal muscular
weakness, as well as appearance of slight erythema over sun-exposed areas and
discrete heliotrope erythema; in addition, he had been presenting on the elbows
some pruriginous erosions for 2 weeks. On admission, his laboratory tests revealed
serum CPK levels of 1930 U/L and increased transaminases. The histopathologic
examination of the lesions confirmed the diagnosis of DH revealing a subepidermal
blister with the presence of neutrophils infiltrating the dermal papillary, on DIF, the
IgA granular deposits were evident. Further serologic tests showed IgA antitissue
transglutaminase of 37.0, ANA of 1:320 speckled. Histopathologic study from
muscle biopsy and the EMG confirmed the diagnosis of an inflammatory myopathy.
Discussion: Hardly any descriptions have been made in the literature about the
specific relationship between dermatomyositis and DH. Two patients have been
reported on the literature as having these diseases in association, in whom they
confirmed the expression of HLA-B8 and HLA-DR3 antigens. This exemplifies the
possible immunopathogenic process related in these 2 entities; however, these HLA
antigens have already been reported in DH without any other associated diseases.
On the other hand, certain clinical presentations of inflammatory myopathies, such
as myositis without any cutaneous manifestations, may be an expression of a
paraneoplastic syndrome. In the case presented, even though very few weeks have
passed since his diagnosis, many tests and screenings have been performed without
having the evidence of a neoplastic process nor other autoimmune disease so far.
The coexistence of these 2 autoimmune entities is very unusual because of the
different autoantigens involved. Concerning the pathogenesis, we suggest that there
may be an underlying immunologic basis with a genetic predisposition for its
presentation; although, in this patient, we do not rule out the possibility of the
existence of multiple autoimmune disorders precipitated by paraneoplastic processes that may not be clinically evident until this moment.
Commercial support: None identified.
Commercial support: None identified.
AB96
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
P7933
P7590
Dysfunctional Toll-like receptor activation in lichen planus
Gabriel Costa de Carvalho, PhD, University of S~ao Paulo Medical School, S~ao
Paulo, Brazil; Eliana Akemi Futata, PhD, University of S~ao Paulo Medical School,
S~ao Paulo, Brazil; Luanda Mara da Silva de Oliveira, PhD, UNiversity of S~ao Paulo
Medical School, S~ao Paulo, Brazil; Maria Notomi Sato, PhD, University of S~ao
Paulo Medical School, S~ao Paulo, Brazil; Rosana Domingues, PhD, University of
S~ao Paulo Medical School, S~ao Paulo, Brazil; Valeria Aoki, MD, PhD, University of
S~ao Paulo Medical School, S~ao Paulo, Brazil
Objective: The aim of this study is to evaluate the profile of TLRs 2-9 activation on the
proinflammatory cytokines responsiveness by peripheral blood mononuclear cells
(PBMCs) of LP individuals.
Background: Lichen planus (LP) is considered a chronic inflammatory mucocutaneous disease affecting 1-2% of the population. LP is of unknown etiology probably
of multifactorial origin, which raises the importance to study the innate immune
response to understand their chronic inflammatory status. Extracellular Toll-like
receptor (TLR) senses bacterial, fungal pathogen associated molecular patterns
(PAMPs) while those intracellular TLRs senses for viral or intracellular bacteria
PAMPs.
Epidermolysis bullosa simplex in Japanese patients: Genetic studies in 16
cases
Satoko Minakawa, MD, PhD, Department of Dermatology, Hirosaki University
Graduate School of Medicine, Hirosaki, Japan; Daisuke Sawamura, MD, PhD,
Department of Dermatology, Hirosaki University Graduate School of Medicine,
Hirosaki, Japan; Hajime Nakano, MD, PhD, Department of Dermatology, Hirosaki
University Graduate School of Medicine, Hirosaki, Japan; Koji Nakajima, MD,
PhD, Department of Dermatology, Hirosaki University Graduate School of
Medicine, Hirosaki, Japan
Methods: The study enrolled LP individuals (n ¼ 13, 12 female, 1 male, age range ¼
29-62) from outpatient clinic of Dermatology Department, Hospital das Clınicas de
S~ao Paulo, and health individuals (n ¼ 10, 9 female, 1 male, age range ¼ 24-57).
PBMCs were cultivated in presence of agonists for TLRs, as PamCSK4 (TLR-2), poly
(I:C) (TLR-3), lipopolysaccharide (LPS, TLR-4), flagelin (TLR-5), imiquimod (TLR-7),
CL097 (TLR-7/TLR8) or CpG (TLR-9) for 48 hrs. Supernatants were assessed for TNF,
IL1-b, and IL-10 measurements using a Flex Set by means of flow cytometry.
Results: The results showed enhanced TNF secretion upon extracellular TLR2,
TLR4, and TLR5 activation in LP individuals compared to healthy controls. In
contrast, the IL-10 was reduced followed TLR-4 stimulation in LP group. Upon
intracellular TLRs activation, LP patients have remarked decrease in TNF and IL-1b
secretion levels via TLR7 activation. Notably, the compound CL097, ligand for
TLR7/TLR8, overcomes the TNF secretion, but not for IL-1b in LP individuals. In
addition, LP individuals showed an increased IL-1b response for TLR9 stimulation.
Conclusion: The findings showed an altered profile of TLRs activation in LP
individuals, with enhanced TNF response for extracellular TLRs stimulation and
absent response for intracellular TLR3 and TLR7 activation. Interestingly,
CL097 through TLR8, suggest an alternative pathway to revert impaired TNF
secretion in LP.
Supported by CNPq/FAPESP/LIM-56/HCFMUSP.
To assess the possibility that epidermolysis bullosa simplex (EBS) may present with
certain specific genotype and phenotype correlation studies in Japanese, we
performed KRT5 and KRT14 mutation analysis by direct sequencing in 16
Japanese patients with EBS and compared them to the previously reported
mutations. We separated into EBS subtypes based on the classification of inherited
epidermolysis bullosa. Basal EBS, localized (EBS-loc) which is previously called EBSWeber-Cockayne was 6 patients. EBS, Dowling-Meara (EBS-DM) was 2 patients. EBS,
other generalized (EBS, gen-nonDM; EBS, gen-nDM) includes previously classified as
having EBS-Koebner was 6 patients. EBS-with mottled pigmentation (EBS-MP) was 1
patient. EBS, migratory circinate (EBS-migr) was 1 patient. Pathogenic mutations
were identified in 13 EBS cases. Three out 5 KRT5 missense mutations were novel.
Two deletions were detected in KRT5. The p.P25L mutation in KRT5, which was
specific for EBS-MP, was again confirmed. Two out of 4 KRT14 missense mutations
were novel. One insertion mutation and 1 deletion mutation were detected in
KRT14. We could not find any mutations in 2 patients. We could not find any clear
distinctions between the EBS generalized type and EBS localized type mutation
positions. The positions of the mutations in both subtypes were more widely
distributed within the rod domains and in the L12 linker domains of both keratin
genes. Lastly, our results confirmed that the mutational location in KRT5 or KRT14 is
the most important factor in determining the phenotype severity. The facts that the
p.R125H mutation in KRT14 was detected in both EBS-DM and EBS-loc and the
p.Y415C mutation in KRT14 was detected in both EBS localized and EBS other
generalized supports the fact that the clinical manifestations may overlap and that
the disease severity is likely to be affected by other factors. All the mutations affect
the important, conserved intermediate filaments amino acids are suggesting that
they may interfere with the keratin heterodimer formation and proteineprotein
interactions, therefore likely to be pathogenic. In general, the ratio of KRT5 and
KRT14 mutations has been reported to be approximately equal. The proportion of
KRT5 mutations (7/13; 53.8%) in Japanese with EBS is higher than that of the KRT14
mutation rate (6/13; 46.2%) in this study.This study should provide useful data and
enhance our understanding of the EBS genotypeephenotype relationship.
Commercial support: None identified.
P8572
Generalized linear IgA following intravenous vancomycin with prominent
palmar involvement
Mark Haeberle, MD, University of Louisville, Louisville, KY, United States; Janine
Malone, MD, University of Louisville, Louisville, KY, United States
P7653
Epidermolysis bullosa acquisita
Shilpi Khetarpal, MD, Cleveland Clinic Foundation, Cleveland, OH, United States;
Melissa Piliang, MD, Cleveland Clinic Foundation, Cleveland, OH, United States;
Pooja Khera, MD, Cleveland Clinic Foundation, Cleveland, OH, United States
A 38-year-old African American female with a history of acute myelogenous leukemia
and systemic lupus erythematosus (SLE) presented with a 1-year history of painful
blisters on her extremities precipitated by minor trauma. She had lost several nails
after injury. It was also noted that when the patient was on prednisone at doses of 40
mg daily or higher for lupus flares, no new blisters formed. Examination revealed
eroded blisters, scarring, and dyspigmentation on elbows, knees, dorsal hands, and
feet. The patient also had anonychia on her right thumb and index finger. Punch
biopsy from the right elbow revealed a pauciinflammatory subepidermal blister
with a superficial and deep perivascular and periadnexal lymphoplasmacytic
infiltrate. Direct immunofluorescence (DIF) revealed positive immunoreactivity in
a granular distribution along the basement membrane with IgG, IgA, IgM, C3, and
fibrinogen. Serologies and DIF were consistent with the patient’s underlying
diagnosis of SLE. In this patient, the major entities under consideration were
epidermolysis bullosa acquisita (EBA) and bullous lupus. These are both blistering
conditions that occur in the setting of SLE and are indistinguishable on histology.
Based on our patient’s age, clinical features, distribution of lesions on trauma-prone
areas, scarring, milia, and cessation of blisters at high doses of prednisone, a
diagnosis of EBA was made. Our patient was started on colchicine 0.6 mg twice daily
and had decreased frequency of new blisters. EBA is a rare, acquired, subepidermal
bullous disease caused by tissue-bound and circulating IgG antibodies to type VII
collagen, which comprises a majority of the anchoring fibrils in the dermoepidermal
junction. EBA is associated with various systemic diseases, including inflammatory
bowel disease, multiple myeloma, rheumatoid arthritis, SLE, thyroiditis, and diabetes
mellitus. Clinically, patients present with noninflammatory bullae that heal with
atrophic scarring, milia, and dyspigmentation in trauma-prone areas. Treatment is
difficult; however, reports suggest that systemic corticosteroids and immunosuppressive medications can be helpful. Other treatment options include gold,
colchicine, IVIG, and dapsone.
Background: Linear IgA bullous dermatosis (LABD) is a subepidermal blistering
disorder characterized mainly by the presence of IgA deposited in a linear fashion
along the basement membrane zone (BMZ). The clinical presentation can be
heterogeneous, although patients most often present with tense bullae mimicking
bullous pemphigoid and some patients may exhibit lesions having herpetiform
morphology. Expanding, annular plaques, scattered lesions, mucosal lesions, and/or
isomorphic responses have also been reported. The disease most often results from
an autoimmune response directed against a protein in the BMZ, more specifically a
97-kDa domain of bullous pemphigoid antigen 2 (BPAG2) termed LABD97. Other
antigens may be targeted in the disease, some of which have not been fully
elucidated. Infections, malignancies, and systemic autoimmune diseases have been
reported to coexist with LABD. Numerous drugs have also been associated with
LABD, with vancomycin being the most frequent.
Commercial support: None identified.
Commercial support: None identified.
Case report: A 69-year-old man with a recent diagnosis of metastatic prostate cancer
was admitted to an outside hospital for treatment of pneumonia. Empiric antibiotics
including levofloxacin, piperacillin plus tazobactam, and vancomycin were started.
The patient developed pruritus and bullae involving the trunk the day after starting
antibiotic therapy, and bullae subsequently developed and progressed to involve
much of his body, including the mucosal surfaces and the palms. The patient was
transferred to a university hospital burn unit. Antibiotics were discontinued and
biopsies were performed, which demonstrated subepithelial bullae with a mixed
inflammatory infiltrate. Subsequent direct immunofluorescence revealed 3+ IgA
deposition in a linear pattern along the basement membrane. Lesions resolved
shortly after discontinuation of antibiotic therapy and with the assistance of local
wound care.
Discussion: We present this case to highlight involvement of the palmar region in
LABD, which may be an underreported feature of the disease. This is one of a few
cases highlighting involvement of the palms by LABD. Other cases reported had
involvement limited to acral sites, whereas our patient developed bullae in a
generalized distribution that included prominent involvement of the palms. LABD
should be a diagnostic consideration in the appropriate clinical setting when there is
vesiculobullous disease involving the palmar surface.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
AB97
P8375
P8717
Giant pyoderma gangrenosum with myiasis
Gonzalo Blasco Morente, PhD, Virgen de las Nieves Universitary Hospital,
Granada, Spain; Aurelio Martın Castro, MD, Virgen de las Nieves Universitary
Hospital, Granada, Spain; Carmen Martınez Peinado, PhD, Virgen de las Nieves
Universitary Hospital, Granada, Spain; Cristina Garrido Colmenero, PhD, Virgen
de las Nieves Universitary Hospital, Granada, Spain; Eliseo Martınez Garcıa, PhD,
Virgen de las Nieves Universitary Hospital, Granada, Spain; Jose AneirosFernandez, PhD, Virgen de las Nieves Universitary Hospital, Granada, Spain;
Salvador Arias Santiago, MD, Virgen de las Nieves Universitary Hospital, Granada,
Spain
Reflectance confocal microscopy as a noninvasive diagnostic tool for
HaileyeHailey disease
Marta Kurzeja, MD, PhD, Department of Dermatology CSK MSW, Warsaw, Poland;
Joanna Czuwara, MD, PhD, Department of Dermatology CSK MSW, Warsaw,
Poland; Lidia Rudnicka, MD, PhD, Lidia Rudnicka, Warszawa, Poland; Malgorzata
Olszewska, MD, PhD, Department of Dermatology Medical University of Warsaw,
Warsaw, Poland
Reflectance confocal microscopy (RCM) allows noninvasive imaging of the
epidermis and superficial dermis. The aim of the study was to evaluate the potential
usefulness of RCM in diagnosing HaileyeHailey disease (familial benign chronic
pemphigus). Three patients with HaileyeHailey disease were examined by RCM.
Skin biopsies were taken at the site of RCM examination to evaluate possible
correlations of RCM with histopathology. In all patients (3/3; 100%) the most
sticking RCM feature was acantholysis resembling a dilapidated brick wall at the
level of the granular and spinous layer. Other RCM features included: crust on
the skin surface, epidermal disarray, intraepidermal clefts, and inflammatory cells in
the epidermis and in the superficial dermis. Detailed analysis revealed a good
correlation between RCM and histopathology findings. In conclusion, reflectance
confocal microscopy examination is a promising noninvasive diagnostic tool for
diagnosing HaileyeHailey disease.
Introduction: Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis
characterized by painful, necrotic ulceration. It typically affects patients in the
third to sixth decades of life, with almost equal incidence in men and women. PG
occurs most frequently on the lower extremities, but it is exceptionally associated
with myiasis. A case of PG with large size and myiasis is reported.
Case report: A 76-year-old woman with a history of hypertension and dyslipidemia
referred recurrent painful ulcer on the legs for 5 years. No other systemic signs. Now
she presented an ulcerated plaque of 20 3 11 cm with irregular edges and fibrinous
center with 2 larvae in her left leg, In contralateral foot, she presented an ulcerated
plaque of 3 cm with similar characteristics. Blood tests were normal, except for
C-reactive protein: 10.2 mg/dL, autoantibodies were negative, and imaging test
found no abnormalities. Histopathology was suggestive of PG. In microbiology fly
larvae were identified, it was unable to classify species. Suspecting PG with myiasis
we retired larvae and prescribed treatment with prednisone 90 mg every 24 hours
and mycophenolate mofetil 500 mg every 24 hours, along with local treatment.
Steroid dose was gradually decreased to 50 mg/day and mycophenolate was
increased to 2 g/day. The patient experienced progressive improvement until
complete resolution of the clinic in 2 months.
Commercial support: None identified.
Discussion: PG is a rare disorder, included in the spectrum of neutrophilic and
autoinflammatory dermatoses. Half of PG cases are seen in association with systemic
disease, not found in our case. Mimickers include infection, vascular insufficiency
ulcers, systemic vasculitis, autoimmune disease, cancer, and exogenous tissue
injury, among others. Misdiagnosis can lead to considerable morbidity, specifically,
unnecessary treatments, multiple ineffective surgeries, and possible amputation. To
the best of our knowledge, we have not found an association between PG and
myiasis described in the literature. Larval therapy is an effective treatment in
debridement of ulcers, but the presence of unsterilized larvae can cause superinfection, so mechanical removal is recommended. Prednisone and cyclosporine have
been mainstays of systemic treatment for PG, although increasing evidence supports
the use of biologic therapies. Our patient improved with treatment with prednisone
1 mg/kg/day and mycophenolate.
Commercial support: None identified.
P7664
Postpartum pemphigoid gestationis
Pamela Morganroth, MD, Henry Ford Hospital, Detroit, MI, United States;
Chauncey McHargue, MD, Henry Ford Hospital, Detroit, MI, United States
Background: Pemphigoid gestationis is a rare vesiculobullous disorder associated
with pregnancy. Although the disease typically presents during late pregnancy, it
can also occur during early pregnancy or in the immediate postpartum period. We
present a case of postpartum pemphigoid gestationis with extensive cutaneous
disease.
Case report: A 24-year-old white female presented with a widespread intensely
pruritic eruption that started 4 days postpartum. The patient had an extensive
cutaneous eruption involving most of her trunk, including the periumbilical area,
and all 4 extremities. Her skin lesions had multiple morphologies, including
polycyclic vesicles overlying erythematous plaques and targetoid erythematous
plaques with dusky centers. Biopsy of a vesicle showed a subepidermal vesicle with
numerous eosniophils. Perilesional direct immunofluorescence showed linear C3
deposition at the dermoepidermal junction. Pemphigoid gestationis was diagnosed,
and the patient was treated with oral prednisone, which resulted in dramatic
improvement within days. The patient’s full-term newborn baby did not have any
cutaneous lesions.
Discussion: Although pemphigoid gestationis typically occurs during pregnancy,
this case reminds us that it can also occur postpartum. Pemphigoid gestationis is
particularly important to recognize because it is associated with an increased risk of
Graves disease, premature delivery, and a small risk of skin lesions in the newborn.
Patient counseling is also essential because pemphigoid gestationis usually recurs in
subsequent pregnancies and may also recur with the menstrual cycle and with oral
contraceptive use.
P8382
Commercial support: None identified.
Commercial support: None identified.
AB98
Resolution of pemphigus foliaceus after hematopoietic stem cell
transplant
Mary Pilcher, MD, West Virginia University, Morgantown, WV, United States;
Rodney Kovach, MD, West Virginia University, Morgantown, WV, United States;
Roxann Powers, MD, West Virginia University, Morgantown, WV, United States
Hematopoietic stem cell transplant (HSCT) has been used for many years to treat
malignancies of the bone marrow and many genetic defects. In recent years, the
concept of treating autoimmune disease with HSCT has gained recognition.
Pemphigus foliaceus is a chronic autoimmune disease that is confined to the skin
and is difficult to treat. Many patients respond to immunosuppressive drugs, such as
prednisone, azathioprine, mycophenolate mofetil, and cyclophosphamide, but must
be maintained on these drugs indefinitely to maintain remission. These patients are
therefore subjected to the long-term side effects of these medications. We present a
case of pemphigus foliaceus in which the patient obtained sustained remission
without need for immunosuppressive medications after HSCT for another
condition.
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
P8001
P7608
T-helper and regulatory T cell cytokines and their correlation with
desmoglein antibody levels in pemphigus vulgaris
Vinod Sharma, MD, All India Institute of Medical Sciences, New Delhi, India;
Manoj Tembhre, MS, All India Institute of Medical Sciences, New Delhi, India
Vancomycin-induced linear IgA bullous dermatosis with isomorphic
phenomenon
Samreen Choudhry, MD, Henry Ford Hospital, Department of Dermatology,
Detroit, MI, United States; Henry W. Lim, MD, Henry Ford Hospital, Department
of Dermatology, Detroit, MI, United States
Background: Pemphigus vulgaris (PV) is an autoimmune skin blistering disease
targeting to cell adhesion molecules, such as desmoglein (Dsg), and characterized by
intraepithelial lesions involving the skin and mucous membrane. The role of
autoreactive T cells and cytokines has been proposed in the etiopathomechanism of
pemphigus that is yet not completely understood. Moreover, correlation between
serum antibodies to desmogleins and cytokines has not been studied.
Objectives: To investigate the status of serum T-helper and regulatory T cell
cytokines in PV and their correlation with antibodies to Dsg-1 and Dsg-3 to establish
cytokines as biomarkers.
Method: Forty patients with active pemphigus and 40 age- and sex-matched healthy
control subjects were included in the study. Serum IL-2, IFN-g, IL-10, IL-13, IL-17A,
and TGF-b1 were measured by enzyme linked immunosorbent assay in both the
groups. In addition, serum Dsg-1 and Dsg-3 levels were estimated in all the PV
patients and were correlated with serum cytokines.
Results: The concentration of IFN-g, IL-17A and TGF-b1 were found to be
significantly higher (P \.05) in PV compared to controls. No significant difference
was observed for IL-2, IL-10, and IL-13 (P [.05) in both groups. Significant positive
correlation was found between Dsg3 levels and cytokines IFN-g and TGF-b1.
Conclusion: Increased levels of IFN-g and IL-17A and TGF-b1 indicated an altered
Th1, Th17, and Treg function. Positive correlation of Dsg-3 antibody with cytokines
IFN-g and TGF-b1 suggest an important role of these cytokines in the pathogenesis
of pemphigus vulgaris.
Commercial support: None identified.
Background: Linear IgA bullous dermatosis is a rare, immune-mediated subepidermal vesiculobullous eruption that occurs because of the linear deposition of IgA in
the lamina lucida of the cutaneous basement membrane. Clinical features range
from erythematous plaques, blanching macules and papules, and targetoid lesions;
however, the most classic presentation is tense bullae in a herpetiform arrangement
simulating a ‘‘cluster of jewels’’ or ‘‘string of beads’’ appearance.
Case report: A 60-year-old morbidly obese white female presented as a transfer from
an outside hospital for a 2-week history of encephalopathy of unknown origin. She
was found to have Clostridium difficile colitis and started on vancomycin and flagyl
for 2 weeks before presentation to our hospital. Because of her poor nutritional
status, a percutaneous endoscopic gastrostomy (PEG) tube was placed. On
admission to our hospital, she was noted to have annular and grouped flaccid
bullae on the bilateral upper lateral thorax in midaxillary line, around PEG tube site,
in a straight line across the right abdomen where her PEG tube was taped across her
abdomen, and oral involvement. The next day, she had involvement of the anterior
aspect of her neck where her nasal cannula was rubbing against her neck. Per her
husband, she had no previous history of skin problems. Extensive laboratory workup for autoimmune, infectious, metabolic, and neurologic causes was significant
only for an elevated erythrocyte sedimentation rate (ESR) at 121 mm/hr and
increased IgA level at 534 mg/dL. A biopsy of one of the blisters revealed a
subepidermal bulla with neutrophilic infiltrate at the base of the bulla. Direct
immunofluorescence showed a 3+ linear IgA/C3 stain at the dermoepidermal
junction. The patient was diagnosed with vancomycin-induced linear IgA bullous
dermatosis and vancomycin was stopped. She was treated with intravenous
immunoglobulin (IVIG) with improvement of her skin lesions, but continued to
medically deteriorate until she passed away on day 3 of IVIG treatment.
Discussion: To our knowledge, there have been 2 case reports in the literature of
isomorphic response seen in patients with drug-induced linear IgA dermatosis. It has
been thought that trauma and friction triggers an increase in local blood flow,
bringing more autoantibodies to the site. The significance of this finding implies that
avoidance of trauma and gentle handling of such patients can lead to early recovery
from a self-limiting disease.
Commercial support: None identified.
INFECTION—BACTERIAL AND PARASITIC
P8644
A case of mucocutaneous leishmaniasis
Aparna Tamirisa, MD, Center for Clinical Studies, Webster, TX, United States;
Christopher Downing, MD, Center for Clinical Studies, Webster, TX, United
States; Farhan Khan, MD, MBA, Center for Clinical Studies, Houston, TX, United
States; Stephen Tyring, MD, PhD, Dermatologic Association of Texas, Webster,
TX, United States
Introduction: Leishmaniasis diagnosed in the United States is usually acquired
outside of the country. We discuss a case of leishmaniasis acquired on a trip to
Venezuela.
Treatment of recalcitrant bullous pemphigoid with rituximab
Anthony Chiaravalloti, SUNY Upstate Medical University, Syracuse, NY, United
States
A 39-year-old woman with severe bullous pemphigoid of 1.5 years’ duration was
referred to our dermatology practice. Her disease had been refractory to multiple
immunosuppressive medications, including high-dose prednisone, methotrexate,
mycophenolate mofetil, and azathioprine with significant morbidity of candida
esophagitis and osteopenia. Based on limited but promising data using rituximab for
recalcitrant bullous pemphigoid, we initiated treatment using doses previously
studied for pemphigus vulgaris. After a total of 10 infusions over a 6-month period
our patient had a lasting remission without additional adjuvant therapy. This report
adds to the growing body of literature that demonstrates rituximab is an efficacious
approach to refractory bullous pemphigoid. If considered earlier in our patient’s
disease course, significant medication-related morbidity may have been avoided. We
recommend that clinicians consider rituximab early in the course of the disease as an
efficacious, steroid-sparing treatment option.
Case report: A 32-year-old male presented with lesions of the right neck and chin and
left nasal ala. On examination, there were multiple erythematous and indurated
papules of the right neck, erythema and swelling of the left nasal ala, and disruption
of the nasal architecture with crusting of the left nare. The lesions began to develop
after he visited the Venezuelan rainforests. He was treated with several antibiotics
without benefit. Repeated biopsies of the left neck showed pseudoepitheliomatous
hyperplasia with seroinflammatory crust and prominent lymphoplasmocytic
inflammation with no growth of microorganisms on staining. Of note, the Giemsa
stain was negative for leishmania. Ultimately, a biopsy sample was sent to the CDC
for tissue culture and PCR analysis which was positive for leishmania. The plan was
to treat the patient with liposomal amphotericin B.
Discussion: Mucocutaneous leishmaniasis is endemic in northern South America
and is associated most commonly with Leishmania braziliensis. Forest rodents are
the reservoirs for L braziliensis, and the transmission vector to humans is the
sandfly. Leishmaniasis is most common between 20 to 40 years of age. Diagnosis in
the US is usually from disease acquired outside of the country, and the primary
endemic area in the US for leishmaniasis is south central Texas. The clinical
manifestations of mucocutaneous leishmaniasis range from edema of the lips and
nose to perforation of the cartilage of the nose and larynx. The characteristic tapir
face is a result of extensive tissue loss in the mouth and nose, as with this patient.
The histologic findings include areas of ulceration with pseudoepitheliomatous
hyperplasia and inflammatory infiltrate. Tissue culture is positive in approximately
40% of cases. The PCR assay method is considered to be the most sensitive and
specific diagnostic test. The differential for mucocutaneous leishmaniasis is paracoccidiomycosis and tertiary syphilis. Wegener granulomatosis and NK T-cell
lymphoma should be considered for lesions affecting the central face. Cutaneous
disease is treated to accelerate healing so as to avoid excess scarring and to prevent
dissemination or relapse of disease.
Commercial support: None identified.
Commercial support: None identified.
P8455
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
AB99
P8683
P8208
An increase in cases of nonnecrotizing granulomatous dermatitis behind
an outbreak of cutaneous leishmaniasis in Madrid, Spain
Azael Freites-Martinez, MD, Servicio de Dermatologia, Hospital Universitario de
Fuenlabrada., Madrid, Spain; Alberto Romero-Mate, MD, Servicio de
Dermatologıa, Hospital Universitario de Fuenlabrada., Madrid, Spain; Almudena
~ez, MD, Servicio de Dermatologıa, Hospital Universitario de
Hernandez-N
un
Fuenlabrada., Madrid, Spain; Angelica Calder
on-Komaromy, MD, Servicio de
Dermatologıa, Hospital Universitario de Fuenlabrada, Spain; Carmen GarcıaDonoso, MD, Servicio de Dermatologıa, Hospital Universitario de Fuenlabrada.,
Madrid, Spain; Jesus Borbujo, MD, PhD, Servicio de Dermatologıa, Hospital
Universitario de Fuenlabrada., Madrid, Spain; Marta Aguado, MD, Servicio de
Dermatologıa, Hospital Universitario de Fuenlabrada, Madrid, Spain
Background: Nonnecrotizing granulomatous dermatitis (NNGD) is defined as an
inflammatory cutaneous infiltrate in which histiocytes are the preponderant cells
without necrosis. Numerous infectious and noninfectious cutaneous disorders fall
within this broad definition. Since October 2010 to April 2013 in the southwest of
Madrid, an increased number of patients with histopathologic characteristics of
NNGD where found, with nondiagnostic clinicopathologic features and lacking
demonstrable microorganisms after bacteriologic, mycologic, or mycobacteriologic
cultures and specific stains (ZiehleNeelsen, Giemsa, periodic acideSchiff).
Objective: To determine the relation of Leishmania spp. to the outbreak of NNGD
between October 2010 to April 2013 a molecular, clinical, and demographic study
based in these cases was performed.
Atypical mycobacteriosis: Case report
Maria Carolina Fidelis, MD, MD, PUC-Campinas, Campinas - SP, Brazil; Adilson
Costa, MD, MD, PUC-Campinas, Campinas - SP, Brazil; Danilo Guerreiro, MD, MD,
PUC-Campinas, Campinas - SP, Brazil; Felipe Borba Calixto Santos, MD, MD, PUCCampinas, Campinas - SP, Brazil; Renan Lage, MD, MD, PUC-Campinas, Campinas
- SP, Brazil; Thaıs Tonso Martins, MD, MD, PUC-Campinas, Campinas - SP, Brazil
Methods: A transversal study including a total of 153 cases of NNGD with no
definitive diagnosis were analyzed with polymerase chain reaction (PCR) amplification of genomic sequences for Leishmania infantum. Clinical and demographic
data was recorded from each case.
Results: One hundred fifty-one cases were positive for L infantum (98.7%).
Erythematous plaques and multiple firm papules with no crust in the surface
were the most frequent clinical presentation (57.6%). Lesions were most often
located in sun-exposed areas and were asymptomatic in 83.4% of cases. Twenty-two
(14.6%) had some type of immunosuppression and there were no clinical
differences compared with immunocompetent patients. The incidence of CL
showed a peak in the age range between 46 and 60 years and was similar in men
and women. One hundred patients (66.2%) were treated with weekly intralesional
infiltrations of meglumine antimoniate with satisfactory resolution of lesions.
Conclusion: CL should be considered among the different causes of NNGD,
especially in endemic areas. PCR may be a useful technique in suspected cases of
CL with no histopathologic diagnosis. Weekly intralesional infiltration of meglumine
antimoniate was the treatment of choice. To our knowledge, this outbreak has the
highest number of cases reported in the twenty-first century in Western Europe.
Introduction: Currently, mycobacterium infections are of great importance in
dermatologic practice, mainly because of an increase in conditions causing
immunosuppression, including HIV infection and immunosuppressive drugs.
Together with the increase of typical mycobacterial infections, such as
Mycobacterium tuberculosis, was also increased atypical mycobacterial infections,
including Mycobacterium chelonae. This mycobacterium is one of the fast growing
mycobacterium, which can affect skin, lungs, lymph nodes, and the skeletal system.
Objectives: This study aimed to describe a rare case of atypical mycobacteriosis in an
adult.
Case report: We report here a case of a 41-year-old woman diagnosed with mixed
connective tissue disease described a progressively growing painless lesions in her
right forearm of 3 months’ duration. She had been using prednisone 1 mg/kg/day
(immunosuppressive dose) and regular pulses of cyclophosphamide for 24 months.
The physical examination showed normochromic nodules, palpable better than
visualize, with a diameter of 1.5-2.0 cm, distributed along the anterior and posterior
sides of the right forearm. The bacilloscopy using ZiehleNeelsen coloration was
positive and the culture using LowensteineJensen medium for mycobacteria was
positive for M chelonae. The diagnosis of atypical mycobacteriosis was confirmed,
and treatment with clarithromycin was instituted.
Discussion and conclusion: In the 1930s, Pinner demonstrated the existence of
nontuberculous mycobacteria, which he named atypical mycobacteria. Although
these mycobacteria have the remarkable characteristic of producing biofilm, they
have low virulence, and therefore do not usually provoke disease in humans.
However, immunosuppressive status have lead to these organisms causing infections in humans since the 1950s. The degree of severity depends on the
mycobacterium virulence, but chiefly on carrier immune. Cutaneous manifestations
include edema, papules, hard to heal ulcers, abscess, subcutaneous nodules, and
multiple or isolated chronic drainage fistulas. The diagnostic confirmation using
affected tissue includes bacilloscopy, histopathologic study, molecular biology,
culture, and RNA probes. There is no randomized control study demonstrating a
specific therapy for these infections; nevertheless, clarithromycin have been used
with few reports of resistance. Our patient was successfully treated with
clarithromycin.
Commercial support: None identified.
Commercial support: None identified.
P8360
Borderline tuberculoid leprosy: Two Brazilian cases
Renata Brand~ao Villa Verde, Universidade Federal Fluminense, Niter
oi, Brazil;
Ant^
onio Sergio Diniz, Universidade Federal Fluminense, Niter
oi, Brazil; En€
oi
Aparecida Guedes Vilar, Universidade Federal Fluminense, Niter
oi, Brazil; Lılian
Viana Barbosa, Universidade Federal Fluminense, Niter
oi, Brazil; Luciana
Pantale~ao, Universidade Federal Fluminense, Niter
oi, Brazil; Maria Claudia de
Almeida Issa, Universidade Federal Fluminense, Niter
oi, Brazil
Case report: A 42-year-old man with multiple sclerosis treated with daily glatiramer
subcutaneous injections—administered at rotating sites on the body for the past
year—presented with 3-week history of an increasingly painful nodule at the left
deltoid injection site. Physical examination revealed a tender erythematous atrophic
plaque with surrounding eschar. No axillary lymphadenopathy or sporotrichoid
spread was present. A punch biopsy and tissue culture was performed. Pathologic
review demonstrated a superficial and deep periadnexal infiltrate comprised of
lymphocytes, neutrophils, histiocytes, a few plasma cells, and rare eosinophils. AFB
and GMS stains were negative for acid-fast and fungal elements. The tissue culture
grew M fortuitum. The patient’s lesion resolved on clarithromycin 500 mg twice
daily and minocycline 100 mg twice daily.
Conclusion: We report a case of M fortuitum caused by the subcutaneous injection
of glatiramer acetate for multiple sclerosis.
Leprosy is a chronic infectious disease caused by Mycobacterium leprae, a Grampositive bacilli, acid-fast, and obligate intracellular. This disease is more common in
developing countries and Brazil is the second place in the world. Case 1 is a 25-yearold man with a 10-cm patch on the abdomen with sensorial deficiency, dyschromic
areas, and satellite erythematous papules for 5 years. Case 2 is an 49-year-old woman
with a 1-cm erythematous papule on the right malar without sensory deficit.
Histologically, both lesions showed granulomatous inflammatory process with
lymphocytes around the nerves and no acid-fast bacilli. The diagnosis was borderline
tuberculoid leprosy. Patients were treated with paucibacillary therapy. Leprosy has
different clinical forms and presents skin and peripheral nerves manifestations. The
RidleyeJopling classification is based on clinical and histopathologic features,
ranging from high to low host resistance, tuberculoid tuberculoid (TT), borderline
tuberculoid (BT), borderline borderline (BB), borderline lepromatous (BL), and
lepromatous lepromatous (LL). The TT and LL forms are clinically stable, but the
others changes according to the immunity. The 2 cases reported was borderline
tuberculoid form, clinically unstable, varying according to pacients immunity. The
clinical features of the BT leprosy are multiple hypoaesthesic well-defined
erythematous infiltrated plaques and papules with asymmetric distribution, with
nerve involvement. The histopathologic features of BT are located between TT and
LL, in which tuberculoid granulomas with rare or absent acid-fast bacilli and difuse
infiltrate of foamy macrophages with Grenz zone and numerous acid-fast bacilli are
found, respectively. In Brazil, the diagnosis of leprosy is based on $ 1 criteria, such
as skin lesion or area with sensory deficit; peripheral nerves involvement with or
without nerves enlargement, sensorial and/or motor and/or autonomic changes;
and positive bacilloscopy. Treatment is defined according to a specific clinical
classification based on the number of lesions. Patients who have up to 5 lesions are
classified as paucibacillar, and [5 lesions or with positive bacilloscopy test as
multibacillar. Paucibacillar patients are treated with rifampicin and dapsone for 6
months. Multibacillar patients are treated for 1 year, adding clofazimine to the
therapeutic regimen.
Commercial support: None identified.
Commercial support: None identified.
P8079
Atypical mycobacerial infection secondary to glatiramer acetate subcutaneous injections in a patient with multiple sclerosis
Michael McCall Jr, MD, University of Louisville Division of Dermatology,
Louisville, KY, United States; Courtney Schadt, MD, University of Louisville
Division of Dermatology, Louisville, KY, United States
Background: Atypical mycobacterial infections have rarely been reported in patients
with multiple sclerosis. Skin infections from fast growing atypical mycobacterium
such as Mycobacterium fortuitum have been reported after trauma in immuocompetent patients, and have also been associated with skin piercings, catheterizations,
and injections. These lesions typically present as small erythematous papules that
generally self-resolve; however, they can progress to large fluctuant abscesses.
Glatiramer acetate is an immunomodulator used to prevent damage to axonal
myelination via unknown mechanisms in multiple sclerosis.
AB100
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
P8347
P7870
Case report: Donovanosis/AIDS successfully treated with doxycycline,
insulin, and zinc hyaluronate
Minh Van Hoang, MD, University of Medicine and Pharmacy of Ho Chi Minh City,
Ho Chi Minh, Vietnam; Cuc Kim Thi Ngo, MD, Ho Chi Minh City Hospital for
Tropical Diseases, Ho Chi Minh, Vietnam; Dat Quoc Ngo, MD, University of
Medicine and Pharmacy of Ho Chi Minh City, Vietnam; Nga Ngoc Cao, PhD,
University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh,
Vietnam; Nhiem Viet Le, MD, Quang Nam Central General Hospital, Quang Nam,
Vietnam; Phung Kim Thi Ngo, MD, PhD, University of Medicine and Pharmacy of
Ho Chi Minh City, Ho Chi Minh, Vietnam
Cutaneous botryomycosis in a patient with advanced Fanconi anemia
Barbara Reichert, Ohio State University College of Medicine, Columbus, OH,
United States; Benjamin Kaffenberger, MD, Ohio State University Division of
Dermatology, Gahanna, OH, United States; Henry Wong, MD, PhD, Ohio State
University Division of Dermatology, Gahanna, OH, United States; Mark Bechtel,
MD, Ohio State University Division of Dermatology, Gahanna, OH, United States
Donovanosis is a chronic, progressively genital ulcer disease that is caused by
Klebsiella granulomatis. It is a rare sexually transmitted disease. This is small
endemic but important issue because it is known to be closely associated with
HIV/AIDS disease. There are very few cases reported in recently several years. We
present the case of a 41-year-old female patient known as HIV infection in state of
AIDS who had been diagnosed vulva cancer before was admitted to hospital with a
huge vulvar ulceration and significant necrosis, loss of right labia majora and labia
minora tissue, and left vulvar swelling, and simultaneously examination result found
a mass in her lower abdomen. The results of ultrasound, CT scan, and MRI of
abdomen and pelvis region showed a big mass in the uteral muscle, clearly limited
without signs of invasion. Histopathology of the skin showing a partial epithelial
ulceration. The intact epithelium had some changes, include hyperkeratosis and
pseudoepitheliomatous hyperplasia. The subcutaneous tissue was infiltrated by
numerous plasma cells, but very rare lymphocyte, many neutrophils. In addition,
many of the epithelioid histocytes and the histocytes were vaculated and many of
these vacuoles contained short rod-shaped organisms, Giemsa staining showed
intracellular Donovan bodies. The patient was diagnosed with Donovanosis-uterine
fibroids/AIDS and was treated with oral doxycycline combined with insulin and zinc
hyaluronate twice a day, and continued to use ART. After 8 weeks, the lesion was
completely healed. This is the first severe case of genital ulcer caused by
Donovanosis and is concurrently diagnosed with uterine fibroids in HIV/AIDS
patient. Since the lesion was assessed severity and prognosis of difficult healing, in
the first time we used more insulin and zinc hyaluronate which were used widely
and proved effective on the treatment of skin wounds, to care for lesion in place,
combined with doxycycline which was recommended on the treatment of
Donovanosis. After 8 weeks of treatment, the lesion was completely healed, we
evaluated that it was rapidly improved for such a severe case of genital ulcer in
HIV/AIDS patient. Therefore this new combination therapy showed great effectiveness on the treatment of Donovanosis, especially for severe lesion cases.
We report a case of a 22-year-old female from Ghana who presented with a 1-month
history of painful lower extremity ulcerations. Her medical history was significant
for Fanconi anemia. She had a bilineage cytopenia with lymphopenia present for the
past 2 years. She denied ulcerations or other skin problems before immigration. She
had no fevers and otherwise only complained of fatigue. The ulcerations appeared as
agminated yellow edematous punched out ulcerations interspersed with fine white
granules that later became crusted. Aside from anemia, leukopenia with neutropenia
and decreased absolute lymphocyte count, all laboratory assessments and cultures
were negative. Punch biopsies showed a perivascular and interstitial dermatitis,
extensive necrosis, and inflamed granulation tissue. Initial fungal, acid-fast bacillus,
and spirochete stains and tissue cultures were negative. She underwent a
debridement, and cultures returned positive for methicillin-sensitive
Staphylococcus aureus and Peptostreptococcus magnus. The clinical picture of
the patient, characteristic bacteria isolated, location of involvement, immunocompromised status, and supportive histopathology led us to the diagnosis of
botryomycosis. After diagnosis, she showed significant improvement with appropriate antimicrobial therapy. Our case portrays the key aspects of a patient with this
rare diagnosis, an infection that typically afflicts those with a cell-mediated
immunodeficiency. Botryomycosis characteristically occurs on the lower extremity,
and common pathogens are S aureus and anaerobes, such as Peptostreptococcus.
Skin manifestations of botryomycosis include nodules, fistulae, and ulcers with
yellow to white 1-3 mm grains and purulent exudate. Histopathology is usually a
nonspecific inflammatory infiltrate, but the SplendoreeHoeppli phenomenon is the
most diagnostic finding if present. As in our patient, treatment of botryomycosis
often requires debridement and long-term antibiotic therapy for complete
resolution.
Commercial support: None identified.
Commercial support: None identified.
P8024
Crusted scabies caused by indiscriminate use of glucocorticoid therapy
Fernanda Lima, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;
Ana Cerqueira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Carolina
Sousa, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Fernanda
Craide, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Manuela
Boleira, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Marina
Bombardelli, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil
Crusted or Norwegian scabies is an uncommon, highly contagious parasitosis of the
skin caused by Sarcoptis scabiei var. hominis. It affects mainly immunossupressed
patients (topical or systemic glucocorticoid therapy, AIDS, human T lymphotropic
virus 1 infection, organ transplant patients). Clinically, it presents with hyperkeratotic dermatoses, acral distribution and the patients may harbor a million mites. The
main complication is the secondary infection. A 4-month-old baby boy, previously
healthy, was admitted with a report of a progressive seborrheic dermatitis despite
treatment. The patient was treated with high potency topical and systemic
corticosteroids continuously in the last 2 months. On examination, the patient
presented with erythematous papules and crusted lesions disseminated over the
body, affecting mainly the trunk and scalp, nail dystrophy and fissures in the
abdomen, also presented moon facies, edema, and systemic signs of septicemia.
Dermoscopy identified numerous mites represented by triangular structures with
following burrow. Skin biopsy was taken from the abdomen, laboratory tests were
ordered, and the child was conducted to hospital treatment. Histologic examination
revealed a burrow with the scabies mite in the papillary dermis. Laboratory tests
revealed leukocytosis, thrombocytopenia, and an increase of inflammatory markers.
Therefore, systemic antibiotic therapy, topical permethrin lotion 1% once a day
were initiated. Relatives were treated with oral ivermectin. On the tenth day of
hospitalization, the patient developed septic shock and despite the treatment the
patient evolved with cardiac arrest and death. We described a dramatic case of
Norwegian scabies. The diagnosis of scabies is often missed initially by nonspecialist
doctors because of the variable presentation. The child was not certainly treated and
the abusive use of glucocorticoids precipitated crusted scabies and the main
complication, secondary infection and sepsis. The evolution was unfavorable and
the child died despite effort attending physicians.
Commercial support: None identified.
P7550
Cutaneous leishmaniasis in the United States: A case and review
Summer Clark, University of Oklahoma College of Medicine, Oklahoma City, OK,
United States; Aurelia Balan, MD, University of Oklahoma, Section of Pediatric
Infectious Diseases, Oklahoma City, OK, United States; Joshua Weingartner, MD,
University of Oklahoma Department of Dermatology, Oklahoma City, OK, United
States; Pamela Allen, MD, University of Oklahoma Department of Dermatology,
Oklahoma City, OK, United States
Leishmaniasis is a protozoan infectious disease caused by organisms of the genus
Leishmania. The disease causes a wide variety of clinical manifestations, depending
both on the infective species and the immune status of the host. In the United States,
infection occurs most often in travelers, but several cases have been reported in
patients from Texas without significant travel history. Here, we present the case of a
pediatric patient from Oklahoma diagnosed with cutaneous leishmaniasis despite
having a travel history significant only for travel to Corpus Christi, TX. The patient’s
case was locally persistent and recurrent over the course of 1 year, despite treatment
with liquid nitrogen cryotherapy. Because of the concern over side effects with
systemic treatments, treatment with topical ketoconazole cream was attempted.
The patient was treated with topical ketoconazole cream for 3 months. Six months
later, the lesion showed no sign of recurrence. This poster will also review
cutaneous leishmaniasis, including its presentation, histopathology, differential
diagnosis, and treatment.
Commercial support: None identified.
MAY 2014
J AM ACAD DERMATOL
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
AB101
P8057
P7705
Difficulty in diagnosing childhood leprosy
Luisa Kelmer Silveira, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro,
Brazil; Marina Wermelinger, MD, Santa Casa da Miseric
ordia do Rio de Janeiro,
Rio de Janeiro, Brazil; Renata Timb
o, Universidade Federal do Rio de Janeiro, Rio
de Janeiro, Brazil
Disseminated Mycobacterium bovis infection in an immunodeficient
child: A case with cutaneous lesions
Gokhan Okan, MD, Medical Park Bahcelievler Hospital Dermatology Department,
Istanbul, Turkey; Didem Atay, MD, Medical Park Bahcelievler Hospital Bone
Marrow Transplantation Unit, Istanbul, Turkey; Esma Turkmen, MD, Medical Park
Bahcelievler Hospital Department of Pediatrics, Istanbul, Turkey; Fatih Erbey,
MD, Medical Park Bahcelievler Hospital Bone Marrow Transplantation Unit,
Istanbul, Turkey; Gulyuz Hanife Ozturk, MD, Medical Park Bahcelievler Hospital
Bone Marrow Transplantation Unit, Istanbul, Turkey; Nesimi Buyukbabani, MD,
Istanbul University Istanbul Medical Faculty Pathology Departmenttt, Istanbul,
Turkey; Orhan Kaya Koksalan, MD, Istanbul University Institute for Medical
Experimental Research Molecular TB Epidemiology Laboratory, Istanbul, Turkey
Introduction: Severe combined immunodeficiency (SCID) is a life-threatening
syndrome of recurrent infections, diarrhea, dermatitis, and failure to thrive. It is
inherited defects of immune system. Babies with SCID are suspectible to severe
infections. Atypical mycobacteria are considered opportunistic pathogens.
Immunodeficient patients are suspectible to disseminated atypical mycobacterial
infections. We present 1-year-old boy with SCID who had disseminated
Mycobacterium bovis infection with cutaneous manifestations.
Introduction: Leprosy is a public health issue in Brazil that also affects the pediatric
age group. The objective of the present study was to call attention to the difficulty
experienced by health care professionals when diagnosing childhood leprosy.
Case report: Y.G.F.R., a 6-year old girl born in Rio de Janeiro and living in Mage,
presented with hypochromic skin lesions that had first been detected 1 year
previously. Her mother had been irregularly treated for tuberculoid leprosy and
reported that earlier the child had been diagnosed and treated for pityriasis
versicolor. Physical examination showed a BCG scar, clearly outlined, infiltrated,
hypochromic plaques on her face and hypochromic macules on her upper limbs and
lower right limb. She weighed 20 kg. Altered sensibility was detected using ether. In
view of the epidemiologic association, the fact that the lesions were suggestive of
leprosy and the altered sensibility, a diagnosis of paucibacillary leprosy of the
borderline tuberculoid type was made. Multidrug therapy was initiated with
pediatric doses in accordance with the patient’s weight.
Discussion: Diagnosing leprosy in childhood when it is not the nodular form of the
disease may be difficult, particularly in undetermined or dimorphous cases
(borderline tuberculoid leprosy) because of the large number of lesions.
Childhood leprosy is a benign variant of tuberculoid leprosy that generally affects
children of 2 to 4 years of age who have been in protracted contact with bacilliferous
patients. For a long time, it was believed that this was the only childhood form of the
disease. Diagnosis is eminently clinical and it is important to emphasize that, of the
dermatologic diseases that constitute possible differential diagnoses (eg, pityriasis
versicolor and vitiligo), leprosy is the only one that causes alterations in sensibility
and furthermore there is almost always an important epidemiologic history. The
course of untreated leprosy in children is unpredictable and may progress to
complete remission with no treatment whatsoever or generate severe sequelae if
untreated because of a delayed diagnosis. The majority of the primary health care
professionals working in the public network in Brazil do not have the experience
necessary to perform a correct and timely diagnosis in this age group, thus affecting
the natural history of the disease, permitting its dissemination and the development
of sequelae that may be incapacitating.
Methods: A 1-year-old boy was referred to our hospital with recurent diarrhea,
cough, fever, and a 1-month history of skin rash on the body. Physical examination
revealed multiple erythematous papular lesions located on the trunk, legs, and arms.
The child underwent an extensive work-up to reach definitive diagnosis. Skin biopsy
was taken.
Results: Laboratory work-up revealed low serum IgM, IgG, and IgA levels. HIV-1 and
2 antibodies were negative. Blood flow cytometry showed low counts of T cell
subtypes. Both radiologic examination and CT scan of the chest showed diffuse
reticulonodular infiltrates of the both lungs. Abdominal ultrasound reveaed
hepatosplenomegaly. MRI of the brain showed numerous hypodens lesions located
on the cerebral hemispheres and brain stem. Histopathology showed noncaseating
granulomatous inflammation in the lower dermis and was positive for acid-fast
bacilli. By polymerase chain reaction, M bovis DNA was detected. With clinical,
radiologic, and histopathologic findings, the diagnosis of miliary M bovis tuberculosis with cutaneous involvement was made
Commercial support: None identified.
Commercial support: None identified.
Conclusion: Skin involvement is unusual in miliary tuberculosis and is usually caused
by underlying immunodeficiency.
P8105
Effect of temperature and time exposure on the survival of scabies mites
and its eggs
Nakaraj Pluetrattanabha, MD, Department of Dermatology, Faculty of Medicine
Siriraj Hospital, Mahidol University, Bangkok, Thailand; Chanai Muanprasart,
Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand; Charussri Leeyaphan, MD, Department of
Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok,
Thailand; Lalita Matthaphan, Department of Dermatology, Faculty of Medicine
Siriraj Hospital, Mahidol University, Bangkok, Thailand; Penvadee
Pattanaprichakul, MD, Department of Dermatology, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok, Thailand; Sumanas Bunyaratavej, MD,
Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand
P8678
Background: Scabies is a common and problematic disease. Scabies can be
controlled by scabicidal method which is important for reducing the recurrence
of this disease. The use of optimal heat and time to kill scabies mites and its eggs is an
easy and practical method.
Disseminated cutaneous botryomycosis
Megan Morrison, DO, St. Joseph Mercy Hospital, Ypsilanti, MI, United States; Ann
LaFond, MD, St. Joseph Mercy Hospital, Ypsilanti, MI, United States; Benjamin
Bashline, DO, St. Joseph Mercy Hospital, Ypsilanti, MI, United States
An 83-year-old African Amerian female presented with a 2-day history of dyspnea
with chest pain and a 1-week history of tender lesions. She had a 3-year history of
squamous cell carcinoma of the lung, which had been treated with radiation and
chemotherapy. Examination revealed multiple small erythematous tender papules,
some with necrotic centers involving the face, right arm, and right leg. A chest
radiograh showed an increased opacification of the left upper lobe. Biopsy of a
lesion the right forearm showed a dense and diffuse acute suppurative infiltrate.
Within the center there were numerous clusters of bacterial colonies arranged in a
‘‘bunch of grapes’’ pattern. The tissue was PAS negative and showed Gram-positive
cocci in clusters. Fresh tissue culture grew out Staphylococcus aureus.
Botryomycosis is a rare granulomatous infectious disease caused by several bacteria,
most commonly S aureus, with the formation of grains. Clinically and histologically
it can resemble other chronic granulomatous diseases and subcutaneous mycoses.
The 2 types of botryomycosis are cutaneous and visceral. Cutaneous is more
frequent and usually appears as a singular plaque with superficial pustules and
crusts. Visceral botryomycosis most commonly involves the lung, and is accompanied by an increase in chest pain and dyspnea. The combined visceral and
disseminated cutaneous presentation in our patient is unique and unreported.
Objective: To study the temperatures and optimal times of killing scabies mites and
its egg hatching.
Methods: Scabies mites were collected from a crusted scabies patient who was first
diagnosed and had not been treated. Infected skin scalings were put on Petri dishes
and divided in 3 groups. One group was incubated in an incubator at 508C compared
to other 2 control groups at 258C and 358C. Survival of scabies mites were evaluated
by survival score ranging from 0-4 (0 ¼ death to 4 ¼ very active movement) at
different time intervals 0, 2, 5, 10, 15, 20, 25, 30, and 35 minutes orderly. Hatched
scabies eggs were counted on day 1, 3, 5, 7, 9, and 11.
Results: At the beginning of the experiment, the average number of scabies mites
per Petri dish was 13.8. The average number of scabies eggs per Petri dish was 270.
After 10 minutes at 508C, there were some alive scabies mites, but their survival
average score was decreasing. All scabies mites were dead (survival score ¼ 0) after
incubated at 508C [35 minutes which had statistically significant difference
between experimental group and control group (P \ .001). After 35 minutes at
258C and 358C, there were mostly alive scabies mites. The same result as scabies eggs
that were continuing hatching on Petri dish at 258C and 358C. On the other hand,
after 35 minutes at 508C, scabies eggs were not hatched from day 1 until day 11 of
the experiment (P \.001).
Conclusion: More than 35 minutes in the temperature 508C can kill all scabies mites
and their eggs.
Commercial support: None identified.
Commercial support: None identified.
AB102
J AM ACAD DERMATOL
MAY 2014
ABS 5.2.0 DTD YMJD9238_9243_proof 8 March 2014 3:17 pm
P8653
P7975
Granuloma venereum: Case report of an oral and perianal location
Rossy Nu~
nez, MD, Instituto Dermatol
ogico Dominicano y Cirugıa de Piel Dr
Huberto Bogaert Dıaz, Santo Domingo, Dominican Republic; Adolfo Arthur, MD,
Instituto Dermatol
ogico Dominicano y Cirugıa de Piel Dr Huberto Bogaert Dıaz,
Santo Domingo, Dominican Republic; Claudio Volquez, MD, Instituto
Dermatol
ogico Dominicano y Cirugıa de Piel Dr Huberto Bogaert Dıaz, Santo
Domingo, Dominican Republic; Eduardo Sanchez, MD, Instituto Dermatol
ogico
Dominicano y Cirugıa de Piel Dr Huberto Bogaert Dıaz, Santo Domingo,
Dominican Republic; Fernanda Nanita, MD, Instituto Dermatol
ogico
Dominicano y Cirugıa de Piel Dr Huberto Bogaert Dıaz, Santo Domingo,
Dominican Republic
In vivo confocal microscopic features of cutaneous leishmaniasis
Ivette Alarcon, MD, Melanoma Unit, Dermatology Department, Hospital Clinic,
Barcelona, Spain; Cristina Carrera, MD, Melanoma Unit, Dermatology
Department, Hospital Clinic, Barcelona, Spain; Jo