A clinicoepidemiological study of geriatric dermatoses

Lichen planus

Objective To analyze the disease constitution, accuracy of clinical and pathological diagnoses of skin biopsy samples in Peking Union Medical College Hospital. Methods A total of 29 987 patients subjected to skin biopsy were collected from Department of Dermatology, Peking Union Medical College Hospital from June 2010 to November 2018, and clinical and histopathological diagnoses of these skin biopsy samples were analyzed retrospectively. Results According to the results of histopathological diagnosis, confirmed diagnoses of these patients could be classified into 33 categories and 242 kinds. Common disease categories included epidermal tumors (2 931 cases, 9.77%) , connective tissue diseases (2 809 cases, 9.37%) , melanocytic tumors (2 078 cases, 6.93%) , erythematous scaly pustular dermatoses (1 376 cases, 4.59%) , lichenoid dermatoses (1 291cases, 4.31%) , allergic or eczematous skin diseases (1 282 cases, 4.28%) and infectious skin diseases (1 156 cases, 3.86%) . Common skin diseases included scleroderma (1 887 cases, 6.29%) , pigmented nevus (1 755 cases, 5.85%) , seborrheic keratosis (1 136 cases, 3.79%) , eczema (1 089 cases, 3.63%) , psoriasis (881 cases, 2.94%) , lichen planus (867 cases, 2.89%) , lupus erythematosus (638 cases, 2.13%) , pemphigus (549 cases, 1.83%) , and basal cell carcinoma (501 cases, 1.67%) . Poor consistency was observed between clinical diagnosis and histopathological diagnosis of lichen planus, bullous pemphigoid, granuloma annulare and hypereosinophilic dermatitis. Conclusions Common disease categories of the skin biopsy samples in Peking Union Medical College Hospital were epidermal tumors, connective tissue diseases, melanocytic tumors, erythematous scaly pustular dermatoses, lichenoid dermatoses, and allergic or eczematous skin diseases. Poor consistency was observed between clinical and pathological diagnosis in some skin diseases, and understanding of these diseases should be improved. Key words: Biopsy; Connective tissue diseases; Nevi and melanomas; Skin diseases, papulosquamous; Lichenoid eruptions; Skin diseases, eczematous

Background and objective Menopause is a significant phase that marks the end of the reproductive years in women and heralds various physiological, hormonal, and psychological changes. There is scarce research on dermatoses in menopause, particularlyin developing countries, where many cases go unreported or undiagnosed due to limited healthcare access and awareness. The study aimed to analyze the clinical pattern of dermatoses in postmenopausal women. Methods We conducted a cross-sectional study involving 200cases of postmenopausal women with dermatoses in any area of the body treated at the Dermatology OPD, Sri Ramachandra Institute of Higher Education and Research (SRIHER) for a period of two years (July 2022-July 2024). A semi-structured questionnaire was circulated, which sought to document data on age,presenting complaints, associated symptoms suggestive of any underlying autoimmune, connective tissue disorder or malignancy,personal and family H/O diabetes mellitus, hypertension, endocrine disorders, cardiovascular diseases, dietary and menstrual history, socioeconomic history, sanitation history, and obstetric history. Results The study included a total of 200 postmenopausal patients who were evaluated for cutaneous, hair, nail, and oral cavity changes. The mean age of the participants was 58.99 ±9.12 years. The age at which menopause started was 40-50 years for most participants(n=127, 63.5%). Occupation-wise, most participants were housewives (n=178, 85.5%). Wrinkles, observed in 149 patients (74.5%), were the common physiological change noted. Of the pathological changes, fungal infections like tinea (n=29, 14.5%)were the most common. Among eczematous conditions, asteatotic eczema, observed in nine patients (4.5%), was the most common; as for papulosquamous disorders, psoriasis (n=22, 11%)was the most frequent condition. Seborrheic keratosis (n=43, 21.5%) was the most frequentbenign tumor; regarding psychocutaneous disorders, lichen simplex chronicus (n=3, 1.5%)was the most commonly encountered condition. Conclusions Postmenopausal dermatoses represent a significant but underrecognized issue related to women's health in India. This study highlights the prevalence of conditions like atrophic vaginitis, lichen planus, and fungal infections in our postmenopausal population.

Combination oral minoxidil and spironolactone for the treatment of androgenetic alopecia in adolescent girls

Haptoglobin (Hp) is an acute-phase reactant, known to be produced mainly in the liver. Haptoglobin can also be detected in the cytoplasm of normal epidermal Langerhans cells (LCs), and can prevent their functional maturation. The synthesis of Hp in skin cells has not been well studied. We examined Hp expression at mRNA and protein levels by in situ hybridization and immunohistochemistry, respectively, in normal human skin and in the skin of patients with psoriasis, lichen planus, erythroderma, seborrheic keratosis, verruca vulgaris, basal cell carcinoma, systemic lupus erythematosus, pemphigus and bullous pemphigoid. (1) Haptoglobin mRNA was expressed in the epidermal keratinocytes (KCs), the epithelial cells of hair follicles, sebaceous glands and eccrine glands in normal skin and all dermatoses investigated. (2) Whereas compared with normal skin, the Hp mRNA in KCs of patients with psoriasis, lichen planus, erythroderma, seborrhoea keratosis and verruca vulgaris was significantly intensified, it was weaker in patients with systemic lupus erythematosus, pemphigus and bullous pemphigoid. (3) Haptoglobin protein only stained positively in some KCs of patients with psoriasis, lichen planus and erythroderma. (4) Although some but not all epidermal LCs were positively stained with anti-Hp antibody in normal skin and in skin samples from all patients, the ratios of Hp-positive LCs/total LCs were significantly higher in those diseases with intensified Hp mRNA in KCs. Skin is another extrahepatic organ where Hp can be synthesized by KCs. The expression of Hp mRNA in KCs and the Hp protein in both LCs and KCs appears to be correlated with the amount of inflammation, which might indicate that skin itself is involved in down-regulating the local inflammatory reaction by KC-synthesized Hp.

Since the introduction of active vaccination against SARS-CoV-2 infection, there has been a debate about the risk of developing severe allergic or anaphylactic reactions among individuals with a history of allergy. Indeed, rare cases of severe allergic reactions have been reported in the United Kingdom and North America. By february 2021 a rate of 4,5 severe allergic reactions occurred among 1 million patients vaccinated with the mRNA-based COVID-19 vaccines, which is higher than the generally expected rate of severe allergic reactions to vaccinations of around 1 in 1 million.

We here thought to dissect the inflammatory signature in lesions of three skin disorders, which show a common adaptive immune response against autoantigens of the skin but are characterized by diverging clinical phenotypes. Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are type-2-dependent, IgG autoantibody-driven blistering disorders of mucous membranes and skin, which target desmoglein (Dsg)3 and bullous pemphigoid (BP)180, respectively. In contrast, lichen planus (LP) is a common chronic inflammatory disease of the skin and mucous membranes with a pronounced dermal T cell infiltrate. We previously identified peripheral type 1 and 17 T cell responses against Dsg3 and BP180 in a cohort of LP patients strongly suggesting that the underlying inflammatory T cell signature may drive the evolving phenotype. Paraffin-embedded skin biopsies from well-characterized patients with LP (n=31), BP (n=19), PV (n=9), and pemphigus foliaceus (PF) (n=2) were analysed. Areas with the most prominent inflammatory infiltrate were excised with punch biopsies and tissue microarrays (TMA) containing multiple biopsies were created. Using multicolor immunofluorescence, the inflammatory infiltrate was stained with antibodies against multiple cellular markers, i. e. CD3ϵ, CD4, CD15, TCR-δ, the cytokine IL-17A, and the transcription factors, T-bet and GATA-3. In LP, there was a higher number of CD4+ T cells expressing T-bet compared to GATA-3. In contrast, CD4+ T cells in PV and BP skin lesions more frequently expressed GATA-3 than T-bet. IL-17A+ cells and IL-17A+ T cells were found to a similar extent in all the three disorders. IL-17A+ granulocytes were more predominant in BP than in LP or PV. Of note, the majority of IL-17A+ cells in LP were neither T cells nor granulocytes. Our findings in inflammatory skin infiltrates clearly show a predominant type 1 signature in LP in contrast to a preponderance of type 2 T cells in PV and BP. In contrast to LP, granulocytes and to a much lesser extent CD3+ T cells were a cellular source of IL-17A in BP and PV. These data strongly suggest that different inflammatory cell signatures drive evolving clinically diverse phenotypes of LP, PV and BP despite common target antigens of the skin.

Objectives: To study the cutaneous manifestations in elderly and their association with gender. Study Design: Cross Sectional study. Setting: Sir Syed Hospital Karachi. Period: Jan 2016 to Jan 2018. Material & Methods: Total 217 geriatric cases (>60 years; both genders) were included from outdoor dermatology clinic. The previous pregnancy, lactation, severe systemic disease and drug induced skin changes were excluded. The association of skin manifestation with gender was analyzed by Chi-square test with significant p<0.05. Results: Among 217 cases, there were 126(58%) females and 91(42%) males. Mean age was 69.3+4.99 years. Wrinkling was seen in 92%, skin laxity in 54.8%, xerosis (43%), dryness (65%), sagging (46%), pigmentation (37%), eczema (25%), sparse hair (21%), skin atrophy (19%), tinea (13%) and LSC (10%). While herpes zoster, psoriasis, onychomycosis, tinea corporis ,asteotic eczema in 7%. Folliculitis 6%, scabies and bullous pemphigoid seen in 5%, while lichen planus, actinic elastosis, BCC, Prurigo nodularis in 3%. Cellulitis, pediculosis, Seborrheic Dermatitis and contact dermatitis were seen in 2% followed by 1% cases of warts, candidiasis, photodermatosis and SCC seen in our study. Folliculitis (6%) was the most frequent bacterial infection followed by impetigo (0.9%). Herpes zoster (6.5%) was frequent among viral infections followed by warts (0.9%) and HSV-1 (0.9%). Tinea (13.4%) was most frequent fungal infection followed by onychomycosis (7%) and candidiasis (0.9%). Scabies was most common parasitic infection (4.6%) followed by pediculosis (2.3%). Eczema seen in 24.8%. The benign dermatosis, Actinic elastosis was frequent (3.2%), stucco keratosis 4(1.8%), Keratoacanthoma (0.9%). Amongst malignancies, BCC was common (3.2%), followed by SCC (1.4%). 5% Bullous Pemphigoid cases were found. The psychocutaneous disorder included LSC (10%), prurigo nodularis (2.8%) and neurotic excoriation (0.9%). Wrinkling, sagging, dryness of skin, actinic keratosis, actinic elastosis was found to be associated with female gender, however cellulitis, squamous cell carcinoma and asteatotic eczema with male gender. Conclusion: Geriatric population is facing multiple dermatological concerns. Contributory factors being the natural aging process, exposure to UV radiation, pathogens, dryness, humidity, temperature and chemical irritants. Female geriatrics are prone to wrinkling, sagging, dryness of skin and male geriatrics to basal cell carcinoma. There is need to address the skin problems in elderly for better quality of life in geriatrics.

Back ground and Objectives: Female pattern hair loss (FPHL), also called as female androgenic alopecia, is one of the common causes of diffuse hair loss in women, characterized by widened midline part in the front of the scalp. Studies have revealed that the FPHL is more common than previously thought and the data pertaining to the same is lacking in the Indian literature. The present study was undertaken to extrapolate the demographic variables and clinical features of FPHL and also to identify the possible risk factors associated with it. Material and Methods: This study was done at our department, involving 100 women with FPHL. Details pertaining to the epidemiological variables, clinical features and risk factors were noted. Results: In the present study, FPHL accounted for 15.3% of diffuse hair loss in women. Mean age and mean age of onset of FPHL among the 100 women was 31.26±9.85 years and 28.03±8.05 years respectively. A positive family history was noted in 51% of patients, with no difference in the age of onset of FPHL in patients with family history positive or negative. The most common pattern of hair loss was diffuse hair loss over the vertex (72%), followed by Oslen pattern (16%) and Hamilton pattern (12%). The age specific frequency of the hair loss severity showed an increase in the severity of FPHL with advancing age (Sinclair grade V was 5.8% in third decade to 74.5% in fifth decade). Polycystic ovarian syndrome, hypothyroidism and BMI more than 25 (overweight and obesity) were noted in 23%, 15% and 65% of patients respectively. Conclusion: FPHL is certainly more frequent than perceived among Indian women. Diffuse hair loss over vertex is the most common pattern of hair loss encountered and the family history does not influence the age of onset and the severity. Overweight and obesity is one of the important risk factor for FPHL. Keywords: Female pattern hair loss, Family history, Obesity

Background: Diffuse alopecia is a psycho-social stressor on human life. As iron is involved in crucial physiological processes within the hair follicle, iron deficiency is suspected to disrupt hair growth. Chronic telogen effluvium (CTE) and female pattern hair loss (FPHL) are the most common causes of chronic diffuse alopecia in females. In both conditions, low iron store have been considered as a possible contributing factor. Materials and Methods: This was a hospital-based case control study, conducted in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University (BSMMU) to evaluate the association of serum ferritin with chronic diffuse alopecia in female patient. Results: The mean age of the females with chronic diffuse hair loss was 26.83±7.78 year and 92.9% females had serum ferritin level <30 ng/ml. The mean serum ferritin level in females with chronic diffuse hair loss, CTE and FPHL were 16.3±11.61 ng/ml,12.35±7.15 ng/ml and 20.25±16.07 ng/ml respectively, which were lower than control 54.37±26.07 ng/ml. A highly significant (p<0.001) difference found in the mean serum ferritin level between the groups. In females with CTE, 42.5% had serum ferritin level < 12ng/ml (iron deficient) and 37.5% had 12-20 ng/ml (iron depletion). In females with FPHL, 23.3% and 30% patients had serum ferritin level <12 ng/ml and 12-20ng/ml respectively. Conclusion: This study found the level of serum ferritin were significantly low in females with chronic diffuse hair loss both in chronic telogen effluvium (CTE) and female pattern hair loss (FPHL), indicating there is a definite association of decreased iron store and diffuse hair loss.

Meaningful patient input to understand disease experience and patient expectations for improvement with treatment is essential for the selection and development of outcome measures for alopecia areata (AA) clinical trials. This study explored the physical signs and symptoms of AA through 30 semistructured interviews with adult (n= 25) and adolescent (n= 5) patients experienced with severe or very severe AA. Scalp hair loss was overwhelmingly the most important sign and symptom of AA. Nearly all patients (90%) considered scalp hair loss in their top three most bothersome physical signs and symptoms of AA, with 77% (n= 23) naming scalp hair loss as the most bothersome symptom. Other identified signs and symptoms in the top three most bothersome included eyebrow, eyelash, nose, body, and facial hair loss, as well as eye irritation and nail damage and/or appearance. Eyebrow (16%, n= 4), eyelash (4%, n= 1), nasal (4%, n= 1), and body (4%, n= 1) hair loss were identified by seven adult patients as the most bothersome signs and symptoms of AA. Conceptual saturation confirmed that a comprehensive understanding of this patient population's physical AA-related signs and symptoms was obtained. These findings indicate that the primary objective for new AA treatments for this patient population should be meaningful improvement in scalp hair growth to address the most troubling unmet need.

The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women

Background Hair fall is a major concern to the patient leading to angst, psychological distress and decrease in quality of life style, more so in female. The aim of the study is to evaluate diffuse hair loss (DHL) in adult females & find the underlying causes. Methods This was an observational, prospective time bound hospital-based study including clinical and trichoscopic evaluation of DHL in women. 222 adult women who had DHL of 4 or more weeks were studied. Detailed history was taken and clinical examination was performed. Laboratory investigations like Hb, Iron Profile, Thyroid Panel was also noted. Trichogram, trichoscopy was performed for perfect visualization of hairs. Results Among the subjects, 95 women were diagnosed as having female pattern hair loss (FPHL), 89 as telogen effluvium, 24 as chronic telogen effluvium (CTE) while 14 had FPHL and TE both. Mean age of females was 33.92 ± 5.46 years. Majority, 145 (65.3%) of the patients were in the age group of 31-40 years. Stress (18%) and PCOD (15%) were the most common precipitating factors. Majority (75.3 %) females with TE have positive hair pull test. Brown peripilar sign (PPS) and white PPS was present in 15.8% and 8.1% women respectively. Conclusions The common causes for DHL are FPHL, TE, CTE and FPHL with TE. Key messages Along with definitive treatment, understanding of the cause of hair loss by the patient goes a long way in appropriate beneficial lifestyle modification and holistic management.

Telogen effluvium (TE) is the most common cause of diffuse hair loss in adult females. TE, along with female pattern hair loss (FPHL) and chronic telogen effluvium (CTE), accounts for the majority of diffuse alopecia cases. Abrupt, rapid, generalized shedding of normal club hairs, 2-3 months after a triggering event like parturition, high fever, major surgery, etc. indicates TE, while gradual diffuse hair loss with thinning of central scalp/widening of central parting line/frontotemporal recession indicates FPHL. Excessive, alarming diffuse shedding coming from a normal looking head with plenty of hairs and without an obvious cause is the hallmark of CTE, which is a distinct entity different from TE and FPHL. Apart from complete blood count and routine urine examination, levels of serum ferritin and T3, T4, and TSH should be checked in all cases of diffuse hair loss without a discernable cause, as iron deficiency and thyroid hormone disorders are the two common conditions often associated with diffuse hair loss, and most of the time, there are no apparent clinical features to suggest them. CTE is often confused with FPHL and can be reliably differentiated from it through biopsy which shows a normal histology in CTE and miniaturization with significant reduction of terminal to vellus hair ratio (T:V < 4:1) in FPHL. Repeated assurance, support, and explanation that the condition represents excessive shedding and not the actual loss of hairs, and it does not lead to baldness, are the guiding principles toward management of TE as well as CTE. TE is self limited and resolves in 3-6 months if the trigger is removed or treated, while the prognosis of CTE is less certain and may take 3-10 years for spontaneous resolution. Topical minoxidil 2% with or without antiandrogens, finestride, hair prosthesis, hair cosmetics, and hair surgery are the therapeutically available options for FPHL management.

Ultrasound scanning is becoming an important diagnostic tool in dermatology. The major advantages of this technique are its non invasive non-ionizing nature and its relatively low cost. We aimed to evaluate the accuracy of ultrasound biomicroscopy (UBM) in the diagnosis of eight skin disorders namely, morphea, keloid, lichen planus, chronic eczema, psoriasis, port wine stain, seborrheic keratosis, and photo-aged skin, through correlation of its findings with clinical and pathological assessment. Fifty seven patients with the above diseases were examined by ultrasound biomicroscopy (UBM). Two areas, one of normal skin and the other from lesional skin, were examined for each patient. Skin biopsies were taken from the same lesion examined by UBM. In morphea, the dermal echogenicity was increased and the thickness of morphea plaques correlated significantly with disease severity. Keloids appeared as low echogenic images. In lichen planus and chronic eczema the dermis appeared as sound shadow. In psoriasis, an intermediate zone between the epidermis and dermis (B zone) was detected. Its thickness correlated significantly with the PASI score. Port wine stain lesions appeared hypoechoic. Seborrheic keratosis appeared as a sound shadow. In photo-aged skin a subepidermal low echogenic band (SLEB) was detected. We conclude that UBM is a non-invasive diagnostic tool in dermatology which can be used to give valuable information about disease progress and the effectiveness of therapy.