Washington D.C. Dermatological Society: 2013 Atlantic Dermatological Conference

WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.

The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.

Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.

To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.

The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."

Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.

"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."

Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.

Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.

For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."

When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.

He said he had no financial conflicts to disclose.

[email protected]

WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.

The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.

Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.

To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.

The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."

Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.

"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."

Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.

Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.

For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."

When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.

He said he had no financial conflicts to disclose.

[email protected]

WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.

The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.

Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.

To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.

The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."

Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.

"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."

Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.

Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.

For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."

When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.

He said he had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – In patients using continued or high doses of retinoids for indications other than acne, monitoring for bone side effects makes sense, Dr. John DiGiovanna said at the Atlantic Dermatological Conference.

The standard courses of isotretinoin used to treat acne have not been shown to be associated with decreased bone mineral density. In addition, recent data from a large, population-based Danish study of fractures including patients taking isotretinoin, acitretin, and topical retinoids showed that none of the retinoids was associated with a change in the risk of fracture at any skeletal site (Arch. Dermatol. 2010;146:478-82).

With prolonged use, however, patients with risk factors such as a family history of osteopenia or osteoporosis and those taking other medications that might contribute to decreased bone density need to be monitored, said Dr. DiGiovanna of the National Cancer Institute, Bethesda, Md.

There are no set rules for such monitoring. Lab tests every 3-6 months are a good starting point, Dr. DiGiovanna said. Also, consider obtaining a radiographic series every 3 years or more frequently if the patient is symptomatic. Imaging should include the cervical and thoracic spine, heels, knees, pelvis, shoulders, and any symptomatic areas.

Retinoid bone toxicity comes in three types: premature epiphyseal closure, diffuse idiopathic skeletal hyperostosis (DISH), and osteopenia/osteoporosis.

Data on the effects of isotretinoin on growth plates are limited, and have generally been associated with high doses, extended treatment duration, and underlying bone demineralization, Dr. DiGiovanna said.

Rare cases of premature closure of epiphyses have been reported in early studies in patients given high doses of retinoids, Dr. DiGiovanna said. He cited the case of a 6-year-old boy whose isotretinoin dose ranged from 0.5 to 4.5 mg/kg per day. At age 9, he reported periodic pain in his right knee, and a radiograph showed diffuse demineralization. At age 10, the pain recurred and imaging showed partial fusion of the proximal tibial growth plate (J. Amer. Acad. Derm. 1982;7:663-6).

In a second case, a 9-year-old boy with a history of high-dose isotretinoin (up to 5 mg/kg per day) for the rare disorder known as fibrodysplasia ossificans progressiva reported leg pain and showed evidence of arrested growth in the form of dense metaphyseal bands on imaging. Normal growth resumed after he discontinued isotretinoin (Am. J. Dis. Child. 1988;142:316-8).

For young children who need continued use of retinoids, a lower dose can be considered until the child achieves full height. Remind parents that the child may need to be re-treated once the epiphyses have fully closed.

DISH has been reported in patients taking retinoids for extended periods of 2 or more years, Dr. DiGiovanna said. In fact, DISH is common in the general population, and most of the time it is asymptomatic.

Some patients weather the bone effects, as in the case of a 52-year-old man with a history of frequent blistering due to generalized epidermolytic hyperkeratosis. Despite developing osteophytes related to stenosis of a neural foramen in the spine, the patient had no neurological symptoms, and wanted to continue retinoids for relief of his skin symptoms. He continues on his therapy and receives yearly MRIs and neurologic evaluations, Dr. DiGiovanna reported.

Regarding the association between retinoid therapy and bone demineralization or osteopenia, "the evidence is really very weak" and there are many risk factors to consider, said Dr. DiGiovanna. "But if you have a patient with a history of osteopenia, for example, a DEXA [dual-energy x-ray absorptiometry] scan is easy to obtain, and there is minimal exposure to radiation."

Remind potentially high-risk patients to stay active, maintain normal vitamin D levels with oral supplementation, and follow a healthy lifestyle, Dr. DiGiovanna said.

The bone density at Ward’s triangle also can be a confounding factor and lead to a misdiagnosis of osteoporosis, said Dr. DiGiovanna.

"Ward’s triangle is not an anatomic area; it is an area of lowest density in the femoral neck," and it is imprecise and positional, he emphasized. In fact, the consensus from osteoporosis experts is that osteoporosis should be measured using the total hip and spine, and not Ward’s triangle.

A randomized trial of acne patients on 1 mg/kg per day of isotretinoin vs. controls showed no significant difference in bone density after 6 months except at Ward’s triangle, he said (Arch. Dermatol. 1999;135:961-5).

Dr. DiGiovanna had no financial conflicts to disclose.

[email protected]

WASHINGTON – In patients using continued or high doses of retinoids for indications other than acne, monitoring for bone side effects makes sense, Dr. John DiGiovanna said at the Atlantic Dermatological Conference.

The standard courses of isotretinoin used to treat acne have not been shown to be associated with decreased bone mineral density. In addition, recent data from a large, population-based Danish study of fractures including patients taking isotretinoin, acitretin, and topical retinoids showed that none of the retinoids was associated with a change in the risk of fracture at any skeletal site (Arch. Dermatol. 2010;146:478-82).

With prolonged use, however, patients with risk factors such as a family history of osteopenia or osteoporosis and those taking other medications that might contribute to decreased bone density need to be monitored, said Dr. DiGiovanna of the National Cancer Institute, Bethesda, Md.

There are no set rules for such monitoring. Lab tests every 3-6 months are a good starting point, Dr. DiGiovanna said. Also, consider obtaining a radiographic series every 3 years or more frequently if the patient is symptomatic. Imaging should include the cervical and thoracic spine, heels, knees, pelvis, shoulders, and any symptomatic areas.

Retinoid bone toxicity comes in three types: premature epiphyseal closure, diffuse idiopathic skeletal hyperostosis (DISH), and osteopenia/osteoporosis.

Data on the effects of isotretinoin on growth plates are limited, and have generally been associated with high doses, extended treatment duration, and underlying bone demineralization, Dr. DiGiovanna said.

Rare cases of premature closure of epiphyses have been reported in early studies in patients given high doses of retinoids, Dr. DiGiovanna said. He cited the case of a 6-year-old boy whose isotretinoin dose ranged from 0.5 to 4.5 mg/kg per day. At age 9, he reported periodic pain in his right knee, and a radiograph showed diffuse demineralization. At age 10, the pain recurred and imaging showed partial fusion of the proximal tibial growth plate (J. Amer. Acad. Derm. 1982;7:663-6).

In a second case, a 9-year-old boy with a history of high-dose isotretinoin (up to 5 mg/kg per day) for the rare disorder known as fibrodysplasia ossificans progressiva reported leg pain and showed evidence of arrested growth in the form of dense metaphyseal bands on imaging. Normal growth resumed after he discontinued isotretinoin (Am. J. Dis. Child. 1988;142:316-8).

For young children who need continued use of retinoids, a lower dose can be considered until the child achieves full height. Remind parents that the child may need to be re-treated once the epiphyses have fully closed.

DISH has been reported in patients taking retinoids for extended periods of 2 or more years, Dr. DiGiovanna said. In fact, DISH is common in the general population, and most of the time it is asymptomatic.

Some patients weather the bone effects, as in the case of a 52-year-old man with a history of frequent blistering due to generalized epidermolytic hyperkeratosis. Despite developing osteophytes related to stenosis of a neural foramen in the spine, the patient had no neurological symptoms, and wanted to continue retinoids for relief of his skin symptoms. He continues on his therapy and receives yearly MRIs and neurologic evaluations, Dr. DiGiovanna reported.

Regarding the association between retinoid therapy and bone demineralization or osteopenia, "the evidence is really very weak" and there are many risk factors to consider, said Dr. DiGiovanna. "But if you have a patient with a history of osteopenia, for example, a DEXA [dual-energy x-ray absorptiometry] scan is easy to obtain, and there is minimal exposure to radiation."

Remind potentially high-risk patients to stay active, maintain normal vitamin D levels with oral supplementation, and follow a healthy lifestyle, Dr. DiGiovanna said.

The bone density at Ward’s triangle also can be a confounding factor and lead to a misdiagnosis of osteoporosis, said Dr. DiGiovanna.

"Ward’s triangle is not an anatomic area; it is an area of lowest density in the femoral neck," and it is imprecise and positional, he emphasized. In fact, the consensus from osteoporosis experts is that osteoporosis should be measured using the total hip and spine, and not Ward’s triangle.

A randomized trial of acne patients on 1 mg/kg per day of isotretinoin vs. controls showed no significant difference in bone density after 6 months except at Ward’s triangle, he said (Arch. Dermatol. 1999;135:961-5).

Dr. DiGiovanna had no financial conflicts to disclose.

[email protected]

WASHINGTON – In patients using continued or high doses of retinoids for indications other than acne, monitoring for bone side effects makes sense, Dr. John DiGiovanna said at the Atlantic Dermatological Conference.

The standard courses of isotretinoin used to treat acne have not been shown to be associated with decreased bone mineral density. In addition, recent data from a large, population-based Danish study of fractures including patients taking isotretinoin, acitretin, and topical retinoids showed that none of the retinoids was associated with a change in the risk of fracture at any skeletal site (Arch. Dermatol. 2010;146:478-82).

With prolonged use, however, patients with risk factors such as a family history of osteopenia or osteoporosis and those taking other medications that might contribute to decreased bone density need to be monitored, said Dr. DiGiovanna of the National Cancer Institute, Bethesda, Md.

There are no set rules for such monitoring. Lab tests every 3-6 months are a good starting point, Dr. DiGiovanna said. Also, consider obtaining a radiographic series every 3 years or more frequently if the patient is symptomatic. Imaging should include the cervical and thoracic spine, heels, knees, pelvis, shoulders, and any symptomatic areas.

Retinoid bone toxicity comes in three types: premature epiphyseal closure, diffuse idiopathic skeletal hyperostosis (DISH), and osteopenia/osteoporosis.

Data on the effects of isotretinoin on growth plates are limited, and have generally been associated with high doses, extended treatment duration, and underlying bone demineralization, Dr. DiGiovanna said.

Rare cases of premature closure of epiphyses have been reported in early studies in patients given high doses of retinoids, Dr. DiGiovanna said. He cited the case of a 6-year-old boy whose isotretinoin dose ranged from 0.5 to 4.5 mg/kg per day. At age 9, he reported periodic pain in his right knee, and a radiograph showed diffuse demineralization. At age 10, the pain recurred and imaging showed partial fusion of the proximal tibial growth plate (J. Amer. Acad. Derm. 1982;7:663-6).

In a second case, a 9-year-old boy with a history of high-dose isotretinoin (up to 5 mg/kg per day) for the rare disorder known as fibrodysplasia ossificans progressiva reported leg pain and showed evidence of arrested growth in the form of dense metaphyseal bands on imaging. Normal growth resumed after he discontinued isotretinoin (Am. J. Dis. Child. 1988;142:316-8).

For young children who need continued use of retinoids, a lower dose can be considered until the child achieves full height. Remind parents that the child may need to be re-treated once the epiphyses have fully closed.

DISH has been reported in patients taking retinoids for extended periods of 2 or more years, Dr. DiGiovanna said. In fact, DISH is common in the general population, and most of the time it is asymptomatic.

Some patients weather the bone effects, as in the case of a 52-year-old man with a history of frequent blistering due to generalized epidermolytic hyperkeratosis. Despite developing osteophytes related to stenosis of a neural foramen in the spine, the patient had no neurological symptoms, and wanted to continue retinoids for relief of his skin symptoms. He continues on his therapy and receives yearly MRIs and neurologic evaluations, Dr. DiGiovanna reported.

Regarding the association between retinoid therapy and bone demineralization or osteopenia, "the evidence is really very weak" and there are many risk factors to consider, said Dr. DiGiovanna. "But if you have a patient with a history of osteopenia, for example, a DEXA [dual-energy x-ray absorptiometry] scan is easy to obtain, and there is minimal exposure to radiation."

Remind potentially high-risk patients to stay active, maintain normal vitamin D levels with oral supplementation, and follow a healthy lifestyle, Dr. DiGiovanna said.

The bone density at Ward’s triangle also can be a confounding factor and lead to a misdiagnosis of osteoporosis, said Dr. DiGiovanna.

"Ward’s triangle is not an anatomic area; it is an area of lowest density in the femoral neck," and it is imprecise and positional, he emphasized. In fact, the consensus from osteoporosis experts is that osteoporosis should be measured using the total hip and spine, and not Ward’s triangle.

A randomized trial of acne patients on 1 mg/kg per day of isotretinoin vs. controls showed no significant difference in bone density after 6 months except at Ward’s triangle, he said (Arch. Dermatol. 1999;135:961-5).

Dr. DiGiovanna had no financial conflicts to disclose.

[email protected]

WASHINGTON – Potentially puzzling hair diseases might be one of three emerging types of alopecia: psoriatic, frontal fibrosing, and permanent chemotherapy induced, according to Dr. Leonard Sperling.

"You have a good chance of seeing these in the coming year," he said.

Psoriatic alopecia claims features of both cicatricial and noncicatricial alopecia, said Dr. Sperling of the Uniformed Services University of the Health Sciences, Bethesda, Md. "It is a histological mimic of alopecia areata," he noted.

However, sebaceous gland atrophy is evident on histology and is a dependable diagnostic feature. "That’s what sets this disease apart," Dr. Sperling said.

A clinical differential diagnosis of psoriatic alopecia may include tinea capitis, chronic cutaneous systemic lupus erythematosus, seborrheic dermatitis, syphilitic alopecia, and psoriasis plus alopecia areata, he said.

Psoriatic alopecia is not new; a case was reported in 1972 (Br. J. Dermatol. 1972;87:73-7).

Clinical studies of treatment outcomes are limited, but one review of data from 47 cases of psoriatic alopecia showed that most patients had complete hair regrowth, although five patients developed residual scarring, Dr. Sperling noted (Dermatology 1992;185:82-7).

"The prognosis for hair regrowth seems to be favorable, but we have more to learn about this condition," he said.

Another emerging hair disease, psoriatic alopecialike reaction to tumor necrosis factor–inhibitor therapy is becoming increasingly common, Dr. Sperling said.

"If you haven’t seen this yet, I predict that you will, as the biologics are more utilized," he said. All the TNF-alpha inhibitors have been associated with this.

It is psoriasis from hell.

"The follicular findings resemble those seen in alopecia areata, in that there is a lot of hair miniaturization" and inflammation, Dr. Sperling said. Numerous different plasma cells and eosinophils are evident on histology, which would be unusual in alopecia areata, he noted. Atrophy of the sebaceous glands also is evident. Recognizing the role of the underlying drug is important to make the diagnosis, he added.

The reason for the atrophy of the sebaceous glands in these cases, as in patients with psoriatic alopecia, remains unknown, Dr. Sperling said.

Frontal fibrosing alopecia is becoming more common, "It’s like an epidemic," said Dr. Sperling. It is becoming more common, especially in the black community, although it was historically described in postmenopausal white women, he said. Frontal fibrosing alopecia can be mistaken for traction alopecia in black women in particular, he noted. However, it can be distinguished from traction alopecia by the loss of eyebrow hair, which might be a clue to consider a biopsy. "The histology is what you would expect in lichen planopilaris," he noted.

Fibrosing alopecia in a pattern distribution is another condition that might be mistaken for lichen planopilaris, Dr. Sperling said. The pattern of hair loss resembles common balding, "but there is inflammation in the zone of thinning," he said. If a biopsy also shows lichenoid changes and obliteration of follicles, consider a diagnosis of fibrosing alopecia in a pattern distribution. "A lot of the inflammation is concentrated around miniaturized hair follicles," he said, but terminal hair follicles are involved as well.

Permanent chemotherapy-induced alopecia occurs in some chemotherapy patients.

"A sizable number of chemotherapy patients develop some type of permanent hair loss after treatment," Dr. Sperling said. Data from biopsies have shown areas of permanent hair loss, but also telogenlike structures, with a curious, amoeboid shape, he said. However, similar structures have been identified in patients with linear morphea, suggesting that these features are not uniquely characteristic of postchemotherapy permanent alopecia, he said.

Instead, they seem to be some sort of end-stage marker for a follicle that isn’t going to grow back, he said.

Dr. Sperling said he had no relevant financial conflicts.

[email protected]

On Twitter @hsplete

WASHINGTON – Potentially puzzling hair diseases might be one of three emerging types of alopecia: psoriatic, frontal fibrosing, and permanent chemotherapy induced, according to Dr. Leonard Sperling.

"You have a good chance of seeing these in the coming year," he said.

Psoriatic alopecia claims features of both cicatricial and noncicatricial alopecia, said Dr. Sperling of the Uniformed Services University of the Health Sciences, Bethesda, Md. "It is a histological mimic of alopecia areata," he noted.

However, sebaceous gland atrophy is evident on histology and is a dependable diagnostic feature. "That’s what sets this disease apart," Dr. Sperling said.

A clinical differential diagnosis of psoriatic alopecia may include tinea capitis, chronic cutaneous systemic lupus erythematosus, seborrheic dermatitis, syphilitic alopecia, and psoriasis plus alopecia areata, he said.

Psoriatic alopecia is not new; a case was reported in 1972 (Br. J. Dermatol. 1972;87:73-7).

Clinical studies of treatment outcomes are limited, but one review of data from 47 cases of psoriatic alopecia showed that most patients had complete hair regrowth, although five patients developed residual scarring, Dr. Sperling noted (Dermatology 1992;185:82-7).

"The prognosis for hair regrowth seems to be favorable, but we have more to learn about this condition," he said.

Another emerging hair disease, psoriatic alopecialike reaction to tumor necrosis factor–inhibitor therapy is becoming increasingly common, Dr. Sperling said.

"If you haven’t seen this yet, I predict that you will, as the biologics are more utilized," he said. All the TNF-alpha inhibitors have been associated with this.

It is psoriasis from hell.

"The follicular findings resemble those seen in alopecia areata, in that there is a lot of hair miniaturization" and inflammation, Dr. Sperling said. Numerous different plasma cells and eosinophils are evident on histology, which would be unusual in alopecia areata, he noted. Atrophy of the sebaceous glands also is evident. Recognizing the role of the underlying drug is important to make the diagnosis, he added.

The reason for the atrophy of the sebaceous glands in these cases, as in patients with psoriatic alopecia, remains unknown, Dr. Sperling said.

Frontal fibrosing alopecia is becoming more common, "It’s like an epidemic," said Dr. Sperling. It is becoming more common, especially in the black community, although it was historically described in postmenopausal white women, he said. Frontal fibrosing alopecia can be mistaken for traction alopecia in black women in particular, he noted. However, it can be distinguished from traction alopecia by the loss of eyebrow hair, which might be a clue to consider a biopsy. "The histology is what you would expect in lichen planopilaris," he noted.

Fibrosing alopecia in a pattern distribution is another condition that might be mistaken for lichen planopilaris, Dr. Sperling said. The pattern of hair loss resembles common balding, "but there is inflammation in the zone of thinning," he said. If a biopsy also shows lichenoid changes and obliteration of follicles, consider a diagnosis of fibrosing alopecia in a pattern distribution. "A lot of the inflammation is concentrated around miniaturized hair follicles," he said, but terminal hair follicles are involved as well.

Permanent chemotherapy-induced alopecia occurs in some chemotherapy patients.

"A sizable number of chemotherapy patients develop some type of permanent hair loss after treatment," Dr. Sperling said. Data from biopsies have shown areas of permanent hair loss, but also telogenlike structures, with a curious, amoeboid shape, he said. However, similar structures have been identified in patients with linear morphea, suggesting that these features are not uniquely characteristic of postchemotherapy permanent alopecia, he said.

Instead, they seem to be some sort of end-stage marker for a follicle that isn’t going to grow back, he said.

Dr. Sperling said he had no relevant financial conflicts.

[email protected]

On Twitter @hsplete

WASHINGTON – Potentially puzzling hair diseases might be one of three emerging types of alopecia: psoriatic, frontal fibrosing, and permanent chemotherapy induced, according to Dr. Leonard Sperling.

"You have a good chance of seeing these in the coming year," he said.

Psoriatic alopecia claims features of both cicatricial and noncicatricial alopecia, said Dr. Sperling of the Uniformed Services University of the Health Sciences, Bethesda, Md. "It is a histological mimic of alopecia areata," he noted.

However, sebaceous gland atrophy is evident on histology and is a dependable diagnostic feature. "That’s what sets this disease apart," Dr. Sperling said.

A clinical differential diagnosis of psoriatic alopecia may include tinea capitis, chronic cutaneous systemic lupus erythematosus, seborrheic dermatitis, syphilitic alopecia, and psoriasis plus alopecia areata, he said.

Psoriatic alopecia is not new; a case was reported in 1972 (Br. J. Dermatol. 1972;87:73-7).

Clinical studies of treatment outcomes are limited, but one review of data from 47 cases of psoriatic alopecia showed that most patients had complete hair regrowth, although five patients developed residual scarring, Dr. Sperling noted (Dermatology 1992;185:82-7).

"The prognosis for hair regrowth seems to be favorable, but we have more to learn about this condition," he said.

Another emerging hair disease, psoriatic alopecialike reaction to tumor necrosis factor–inhibitor therapy is becoming increasingly common, Dr. Sperling said.

"If you haven’t seen this yet, I predict that you will, as the biologics are more utilized," he said. All the TNF-alpha inhibitors have been associated with this.

It is psoriasis from hell.

"The follicular findings resemble those seen in alopecia areata, in that there is a lot of hair miniaturization" and inflammation, Dr. Sperling said. Numerous different plasma cells and eosinophils are evident on histology, which would be unusual in alopecia areata, he noted. Atrophy of the sebaceous glands also is evident. Recognizing the role of the underlying drug is important to make the diagnosis, he added.

The reason for the atrophy of the sebaceous glands in these cases, as in patients with psoriatic alopecia, remains unknown, Dr. Sperling said.

Frontal fibrosing alopecia is becoming more common, "It’s like an epidemic," said Dr. Sperling. It is becoming more common, especially in the black community, although it was historically described in postmenopausal white women, he said. Frontal fibrosing alopecia can be mistaken for traction alopecia in black women in particular, he noted. However, it can be distinguished from traction alopecia by the loss of eyebrow hair, which might be a clue to consider a biopsy. "The histology is what you would expect in lichen planopilaris," he noted.

Fibrosing alopecia in a pattern distribution is another condition that might be mistaken for lichen planopilaris, Dr. Sperling said. The pattern of hair loss resembles common balding, "but there is inflammation in the zone of thinning," he said. If a biopsy also shows lichenoid changes and obliteration of follicles, consider a diagnosis of fibrosing alopecia in a pattern distribution. "A lot of the inflammation is concentrated around miniaturized hair follicles," he said, but terminal hair follicles are involved as well.

Permanent chemotherapy-induced alopecia occurs in some chemotherapy patients.

"A sizable number of chemotherapy patients develop some type of permanent hair loss after treatment," Dr. Sperling said. Data from biopsies have shown areas of permanent hair loss, but also telogenlike structures, with a curious, amoeboid shape, he said. However, similar structures have been identified in patients with linear morphea, suggesting that these features are not uniquely characteristic of postchemotherapy permanent alopecia, he said.

Instead, they seem to be some sort of end-stage marker for a follicle that isn’t going to grow back, he said.

Dr. Sperling said he had no relevant financial conflicts.

[email protected]

On Twitter @hsplete