Wood's Light Examination Research Articles

Microneedling with glutathione versus microneedling alone in treatment of facial melasma: Split-face comparative study.

Melasma is a distressing disfiguring acquired pigmentary disorder especially affecting females and it is of high tendency of recurrence. Up till now, treatment of melasma is a challenging problem. We evaluated the effectiveness of microneedling with glutathione versus microneedling alone in treatment of melasma. In this study, 29 adult females with epidermal type of melasma (confirmed with Wood's light examination) were enrolled. The affected area was subjected to microneedling using dermapen followed by application of glutathione solution on the right side only. This session was performed every 2 weeks for 3 months (six sessions for every patient). The response to therapy was measured using modified melasma area and severity index (m MASI) that were calculated on each side of the face (Hemi- m MASI) before treatment sessions. There was statistically significant reduction in the mean of Hemi- m MASI score over the sessions on both sides of the face but the right side (microneedling with glutathione) showed more reduction and earlier response to therapy than the left side (microneedling alone). On the left side, mean of Hemi- m MASI score before and after sessions was (4.06 ± 1.91, 2.31 ± 1.450) and on the right side, it was (4.21 ± 2.08, 1.96 ± 1.30), respectively and this was statistically significant. Percentage of improvement on the left side was 46.92 ± 16.30 (%) while on the right side was 55.17 ± 15.50 (%) and this was statistically significant. Microneedling is an effective promising tool in treatment of melasma and its combination with glutathione as a whitening agent, increases and accelerates its efficacy. So, combined therapy is more preferred than monotherapy in treatment of facial melasma.

Dermoscopic Examination in Malassezia folliculitis

Background: Malassezia folliculitis (MF) is the most common fungal folliculitis, and it is caused by yeast of the genus Malassezia. MF may be difficult to be distinguished clinically from acne and other types of folliculitis, causing misdiagnosis and improper treatment. Dermoscopy has been very useful to support the diagnosis of several types of folliculitis, including MF. Purpose: To know the role of dermoscopic examination in MF. Review: The diagnosis of MF can be identified by usual clinical presentation with direct microscopy and culture of the specimen, Wood's light examination, histopathological examination, and rapid efficacy of oral antifungal treatments. Several studies reported that dermoscopy provides a deeper level of the image that links the clinical morphology and the underlying histopathology. Some dermoscopic patterns are observed consistently with certain diseases, including MF, so these could be used for establishing their diagnosis. The dermoscopic features of MF seem to correlate with the current understanding of its etiopathogenesis. Conclusion: Dermoscopic examination in MF will reveal dermoscopic patterns including folliculocentric papule and pustules with surrounding erythema, dirty white perilesional scales, coiled/looped hairs with perifollicular erythema and scaling, hypopigmentation of involved hair follicles, and dotted vessels.

Perialar intertrigo in children and adolescents: A multicenter prospective study of 41 cases.

We observed isolated cases of perialar intertrigo in children and teenagers that did not appear to correspond to any known clinical entity. The objective of this study was to describe the clinical features of this dermatosis and the clinical characteristics of the patients. We conducted a prospective, multicenter cohort study in France from August 2017 to November 2019. All the patients under 18 years of age with chronic perinasal intertrigo were included. A standardized questionnaire detailing the clinical characteristics of the patients and the description of the intertrigo. If possible, a Wood's lamp examination of the intertrigo was done. Forty-one patients were included (25 boys and 16 girls, average age: 12.1 years). Intertrigo was bilateral in 38 patients (93%). The majority of patients had no symptoms (54%). Pruritus was present in 39% of cases. Orange red follicular fluorescence was present in the perialar region on Wood's light examination in 78% of cases with active fluorescence. The presumptive diagnoses suggested by the investigators were acne (24.4%), seborrheic dermatitis (19.5%), rosacea (9.8%), psoriasis (9.8%) and perioral dermatitis (7.3%). No diagnosis was proposed in 22% of the cases. We describe a previously undescribed clinical sign which is characterized by a chronic bilateral erythematous intertrigo located in the perialar region. It can be isolated or associated with various facial dermatoses.

Identification of Malassezia Species Isolated from Pityriasis Versicolor by CHROMagar-Medium

Abstract Background Pityriasis versicolor is a chronic superficial fungal infection seen worldwide, with high prevalence observed in hot and humid climates. Objectives The aim of this work was to isolate and identify Malassezia species from pityriasis versicolor using specific fast gtowth media; Chrom agar to obtain a better understanding of the role of each species in the etiology of disease. Patients and Methods This study was conducted on 70 patients with clinical diagnosis of pityriasis versicolor with positive KOH test. All of the participants were subjected to a well informed consents, full history taking including age, sex, site of the lesions and any previous treatment, full general and dermatological examination to determine site, color of the lesions and Wood's light examination. Results Our results reported 94.3% of studied patients yielded growth on culture while 5.7% did not show any growth. The predominant age group was ≥ 25 years old. Furthermore it was found that PV affected male subjects (62.90%) more than the females (37.1%). Conclusion Malassezia yeasts, although are considered a part of normal skin microbiome, is a known cause of pityriasis versicolor. PV was more common in males in the age group ≥ 25yrs. The most affected body site was the chest, the most common variant is hyperpigmented type, and the commonest isolate was M.furfur.

Prevalence of Hypopigmentary Disorders in Primary School Children in Zagazig City, Sharkia Governorate, Egypt.

Epidemiologic data derived from population-based studies are very important to understand human diseases and their implications. Highlighting skin problems by identifying their incidence and prevalence is vital to direct suitable medical attention toward them. The aim of the study was to detect the prevalence and most common causes of hypopigmentation in primary school children in Zagazig City. Cross-sectional study on 185 students selected from two schools. Data were collected by filling a questionnaire, clinical examination, and Wood's light examination to detect hypopigmented skin disorders. The prevalence of hypopigmentation among studied population was 45.4%; the commonest cause was pityriasis alba 58.3%, followed by pityriasis versicolor 17.9%, postinflammatory hypopigmentation 10.7%, hypopigmented nevus 9.5%, and finally 3.6% vitiligo. Hypopigmented skin disorders are important and easy to diagnosis skin diseases that need medical attention.

Efficacy and safety of tranexamic acid 5% cream vs hydroquinone 4% cream in treating melasma: A split-face comparative clinical, histopathological, and antera 3D camera study.

Various tranexamic acid (TA) formulations have been evaluated for treating melasma, yet the effectiveness of this therapy has not been efficiently comparatively analyzed. To assess and compare the therapeutic efficacy and safety of TA 5% vs hydroquinone (HQ) 4% creams in treating melasma. 100 melasma female patients were treated with daily application of TA 5% cream on right-sided facial lesions and HQ 4% cream on left-sided lesions for 12 weeks. Photographic documentation using digital and Antera 3D camera, Wood's light examination, calculation of Hemi Melasma Area and Severity Index (Hemi MASI), Melasma quality of life (MELASQOL) scores and area% of melanin through histopathological examination was done before and after treatment. Both TA 5% and HQ 4% creams yielded significant improvement of all melasma lesions after 12 weeks of treatment, with no significant difference in treatment response regarding Hemi MASI, MELASQOL scores and Antera average level of melanin (P > .05); however, significant reduction in area % of melanin was recorded with TA 5% than HQ 4% creams (P = .000). TA appears to be a promising therapeutic option in treating melasma with fewer adverse effects, same or even better results in comparison to HQ cream.

Ultraviolet imaging in dermatology.

Visual examination plays a central role in the diagnosis of skin diseases. Many dermatologists use magnification, or dermoscopy, to improve diagnostic certainty when assessing the skin under visible light. In addition to magnification, other technological advances have been made over the last century to improve our visual assessment of the skin. Examination of skin under ultraviolet (UV) radiation, with Wood's light, gained traction for its utility in assessing superficial cutaneous infections and pigmentary changes. During Wood's light examination, UV light is directed at the skin and fluorescence is detected by our eyes. The variable fluorescent characteristics of endogenous and exogenous cutaneous chromophores help us better diagnose skin disease. UV fluorescent photography is based on the same concept as the Wood's light, but also allows image analysis and documentation of the captured image. In addition to UV-induced fluorescence, the differential reflection and absorption of UV light captured in the UV spectral range can also provide a new contrast for diagnosing skin diseases during UV reflectance photography. This review discusses the most widely used UV imaging techniques and provides an overview of the role of UV imaging in dermatology.

Wood's light examination for assessment in frontal fibrosing alopecia: A maneuver to enhance the hairline

Wood's light examination for assessment in frontal fibrosing alopecia: A maneuver to enhance the hairline

Profil épidémio-clinique et étiologique des teignes du cuir chevelu chez l’adulte à Dakar (Sénégal)

To determine the epidemiological and etiological profile of tinea capitis in adults in Dakar (Senegal). A 9-month prospective, multicenter, descriptive and analytic study. Patients included were aged over 18 years. Mycological tests were used to confirm the diagnosis. 121 patients were included with a mean age of 36.1 years and a hospitalisation frequency of 0.8%. The age range of 64.4% of patients was between19 and 38 years. 51% of patients were housewives. A low socioeconomic level was found in 72.8% of cases. In 3.3% of patients, the disease began in childhood. 31.4% of patients had already consulted a traditional healer. Similar familial cases were noted in 60.3% of patients. Contact with a sheep was noted in 32.2% of cases, deliberate skin lightening in 64% of women, hair salon attendance in 46.7% of women, and immunosuppression in 17.3% of patients, while itching was present in 95.5%. Dermatologic examination showed scaled plaques and a diffuse form, with 92.6% and 64% (n=75) respectively. Wood's light examination was positive in 40.2% of patients. A positive culture test was found in 71%. The most frequently encountered species were: T.soudanense (65%), M.audouinii (21%), T.rubrum (4.7%), M.gypseum (3.5%), T.violaceum (2.3%), T.verrucosum (2.3%) and M.canis (1 case). The clinical course was favorable under treatment with griseofulvin or terbinafine. Tinea capitis in adults mainly affects young women. The diffuse form is the most common. The most frequently encountered species was T.soudanense.

Clinical markers of vitiligo activity

Current modalities of understanding disease state (active/stable) are limited when considering treatment of vitiligo. We sought to develop a rapid, accurate, and noninvasive assessment of vitiligo state. In daylight and Wood's light examinations, 2 common clinical types of vitiligo were identified as amelanotic with sharply demarcated borders and hypomelanotic with poorly defined borders. Photographs were taken at the time of examination and a skin biopsy at the edge of a vitiligo lesion was performed. One year after the initial visit, the vitiligo was classified as stable if no new lesions had appeared, and as active if the number, size, or both of existing vitiligo lesions were increased. Skin biopsy specimens from 71 patients were stained and immunostained for melanocytes, CD8+ T lymphocytes, and E-cadherin. The active lesions were associated with hypomelanotic appearance with poorly defined borders (P<.001), and histologically with an infiltration of CD8+ T lymphocytes in the epidermis and dermis (P=.017), with a strong expression of E-cadherin (P=.044). The fact that this was a single-center study and that activity was sometimes site-dependent are limitations. The hypomelanotic with poorly defined borders type could be a good indicator of the actual activity of a vitiligo lesion.

A Case of Segmental Vitiligo with Generalized Morphea Stabilized by Antimalarial Medication.

Dear Editor: A 10-year-old girl presented with a round, brown to whitish, atrophic plaque on the right side of her back, which she has had for 5 years. Histologic findings showed thick collagen bundles with lymphocytic infiltrations around the vessel in the dermo-subcutaneous tissue, which are consistent with morphea. Only topical calcipotriol was used due to the limited localization of the plaque and the young age of the patient. However, after 6 months, a new morphea lesion developed on the left side of the back and linear scleroderma occurred on the forehead. The patient was diagnosed with generalized mixed-type morphea, with two circumscribed morphea on the right and left sides of the back (Fig. 1A) and linear scleroderma on the forehead (Fig. 1B). Hypopigmented lesions were also present on her left leg and on the left side of the trunk (Fig. 1C). Based on Wood's light examination and clinical findings, the patient was diagnosed with segmental vitiligo (SV). Fig. 1 (A) Two circumscribed morphea on the right and left sides of the back. (B) Linear scleroderma on the left side of the forehead. (C) Vitiliginous lesions on the left side of the trunk. The vitiliginous lesions and linear scleroderma on the forehead showed progression despite the combination therapy using intermittent oral steroid, topical calcineurin inhibitor, and narrowband ultraviolet B phototherapy for 1 year. To block the progression of morphea, hydroxychloroquine sulfate (200 mg/day) was used. Skin lesions of morphea and vitiligo stabilized within 6 weeks. In addition, the vitiliginous lesions showed 70% repigmentation after 5 months from start of medication. Skin lesions of morphea also showed no more progression. The patient tolerated the 7-month treatment period with no side effects (Fig. 2). Fig. 2 Flow diagram during the follow-up period. NBUVB: narrowband ultraviolet B. Although the pathogenesis of vitiligo remains unknown, an immunological mechanism is strongly considered. However, SV is associated with a neurogenic mechanism. Furthermore, an immune-mediated mechanism known as the three-step theory has been reported to be involved in the pathogenesis of SV, according to a case report showing simultaneous occurrence of SV, alopecia areata, psoriasis, and halo nevus1. The association of SV with scleroderma has been rarely reported2. Bonifati et al.3 reported the case showing linear scleroderma on the left limb and homolateral SV on the trunk. Contrary to previous reports, our patient had generalized morphea lesions on the right and left sides of the back and linear scleroderma on the left side of the forehead, which was on the same side of the body where SV was located. Our case study suggested that hydroxychloroquine is effective not only in blocking the progression of scleroderma4 but also in treating vitiligo. Walsh et al.5 reported two systemic lupus erythematosus patients with exextensive widespread vitiligo-like depigmentations who showed rapid responses to hydroxychloroquine. Although we cannot exclude the possibility of coincidental development of SV and scleroderma, our case suggested that vitiligo and scleroderma that have the same autoimmune background can occur at the same time because they occurred during the same period and progressed in parallel for several years. In addition, this concomitant presence could support the theory that SV is associated with an autoimmune background. Moreover, our report suggested that an antimalarial drug could be used as a promising option for the treatment of vitiligo.

Clinical and epidemiological features of coryneform skin infections at a tertiary hospital.

Background:Skin infections caused by coryneform bacteria are common dermatological conditions. However, to the best of our knowledge, no studies are available on the clinical characteristics and epidemiological features of this group of disorders as one entity from India and abroad.Aims:To study the clinical and epidemiological features of coryneform skin infectionsMethods:A total of 75 patients presenting with clinically distinctive lesions of pitted keratolysis, erythrasma and trichobacteriosis to our hospital were included in the study. Cases were interviewed with particular emphasis on epidemiological features and the various clinical findings were recorded. Investigations like Gram's stain, Wood's light examination, 10% KOH scrapings, were done in selected cases to ascertain the diagnosis.Results:Pitted keratolysis was more common in the age group of 31-40 years (40%) with a male preponderance (76.7%), most commonly affecting pressure bearing areas of the soles with malodour (86.7%) and frequent contact with water (58.3%) constituting the most important presenting symptom and provocating factor respectively. Erythrasma affected both male and female patients equally and was more commonly detected in patients with a BMI > 23kg/m2 (62.5%) and in diabetics (50%). All patients with trichobacteriosis presented with yellow coloured concretions in the axillae. Bromhidrosis (71.4%) and failure to regularly use an axillary deodorant (71.4%) were the most common presenting symptom and predisposing factor respectively.Conclusion:Coryneform skin infections are common dermatological conditions, though epidemiological data are fragmentary. Hyperhidrosis is a common predisposing factor to all three coryneform skin infections. Asymmetrical distribution of pits has been reported in our study. Diabetic status needs to be evaluated in all patients with erythrasma. Woods lamp examination forms an indispensible tool to diagnose erythrasma and trichobacteriosis.

Study of the Etiological Causes of Toe Web Space Lesions in Cairo, Egypt.

Background. The etiology of foot intertrigo is varied. Several pathogens and skin conditions might play a role in toe web space lesions. Objective. To identify the possible etiological causes of toe web space lesions. Methods. 100 Egyptian patients were enrolled in this study (72 females and 28 males). Their ages ranged from 18 to 79 years. For every patient, detailed history taking, general and skin examinations, and investigations including Wood's light examination, skin scraping for potassium hydroxide test, skin swabs for bacterial isolation, and skin biopsy all were done. Results. Among the 100 patients, positive Wood's light fluorescence was observed in 24 and positive bacterial growth was observed in 85. With skin biopsy, 52 patients showed features characteristic for eczema, 25 showed features characteristic for fungus, 19 showed features characteristic for callosity, and 3 showed features characteristic for wart while in only 1 patient the features were characteristic for lichen planus. Conclusion. Toe web space lesions are caused by different etiological factors. The most common was interdigital eczema (52%) followed by fungal infection (25%). We suggest that patients who do not respond to antifungals should be reexamined for another primary or secondary dermatologic condition that may resemble interdigital fungal infection.

Hypertrichosis Is Not so Prevalent in Becker's Nevus: Analysis of 47 Cases.

Becker's nevus is a relatively common cutaneous hamartoma, but is often overlooked or misdiagnosed. This nevus usually begins during the second decade of life as a circumscribed, hyperpigmented patch with irregular outline that gradually enlarges with associated hypertrichosis, developing several years later. The purpose of this study was to determine the prevalence of lesional hypertrichosis associated with Becker's nevus. Methods. 47 patients who had sharply demarcated brown patch with or without coarse hair, presence or enlargement of the lesion at the time of puberty, and compatible Wood's light examination were enrolled. Patients who had axillary freckling, previous skin inflammation, and gray pigmentation of the lesions were excluded. Results. In summary, the mean age of onset was 11.89 (range 0–19). The most commonly involved site was the arm (34%), followed by shoulder (23.4%), chest, face, flank, buttock, and leg. Lesional hypertrichosis was found in only 8 (17%) of the 47 patients. In 29 cases (61.7%) the lesions were in the right side of the body. Conclusion. Hypertrichosis was not so frequent among patients with Becker's nevus. There was a higher preponderance of the lesions on the right side.

Segmental vitiligo and extragenital lichen sclerosus et atrophicus simultaneously occurring on the opposite sides of the abdomen.

Dear Editor: A 10-year-old female patient visited the dermatology clinic because of hypopigmented skin lesions on both sides of her abdomen that occurred 3 years ago (Fig. 1A, B). There were no associated symptoms or history of infectious diseases, stressful events, or trauma. Her parents did not recall any history of familial autoimmune diseases. Laboratory tests on autoimmune panels (antinuclear antibody, anti-DNA screening, anti-Scl 70) were all negative. On Wood's light examination, hypopigmented lesions on the right abdomen showed marked accentuation that was clinically consistent with segmental vitiligo (SV). On the other hand, the lesions on the left side of the abdomen revealed only mild accentuation. Whereas biopsy was not performed on the lesion suspicious for SV, histopathological examination of a hypopigmented plaque on the patient's left abdomen showed follicular plugging and fibrosis with edema in the upper dermis, suggesting lichen sclerosus et atrophicus (LSA) (Fig. 1C, D). Although rare, there are incidences of morphea presenting with vitiligo, requiring attentive differential diagnosis with LSA. Yet, features that suggest morphea, such as thickened collagen bundles or atrophic eccrine glands, were not seen. Fig. 1 (A) Well-demarcated hypopigmented patches without surface changes on the right abdomen. (B) Multiple hypopigmented papules and plaques occurring with atrophic surface change and hardening on the left abdomen. The lesions shown in both (A) and (B) had ... There have been previous reports of SV and LSA occurring simultaneously. However, most of the reported cases were SV that co-occurs with genital LSA1,2 or extragenital LSA in a non-SV (NSV) patient3. Thus, to our knowledge, we here report the first case of extragenital LSA occurring with SV. The significance of LSA and SV of synchronous onset can be interpreted as a deviation from a previously known mechanism for SV. Also, we believe that it suggests a possible relation between the mechanisms of two very different diseases. Although an exact pathomechanism for LSA is not yet known, there is an unproven consensus that LSA is an autoimmune disease, on the basis of evidences such as the presence of circulating antibodies targeting extracellular matrix protein 1 and the frequent association of LSA with other autoimmune diseases4. Concerning SV, although it is mostly thought to involve a neural mechanism, there is a view that an autoimmune basis adds to its onset as well. A case report on SV occurring concurrently with alopecia areata, psoriasis, and halo nevus supports this hypothesis, as the three diseases except SV are known to have an autoimmune basis5. Hence, from our interesting case of SV and LSA occurring on the opposite sides of the abdomen along Blashko's line, we suggest that there is a possibility of a common initiating factor or a shared pathomechanism existing between SV and LSA. Furthermore, if autoimmunity or auto-inflammatory reaction takes place in the onset of SV, our case could provide supporting evidence for SV sharing a common link with NSV.

Confluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Min Z, Tan C, Xu P, Zhu W. Letter to the EditorConfluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2014;31(5):335-337. doi:10.5114/pdia.2014.44011. APA Min, Z., Tan, C., Xu, P., & Zhu, W. (2014). Letter to the EditorConfluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 31(5), 335-337. https://doi.org/10.5114/pdia.2014.44011 Chicago Min, Zhong-Sheng, Cheng Tan, Ping Xu, and Wen-Yuan Zhu. 2014. "Letter to the EditorConfluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques". Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii 31 (5): 335-337. doi:10.5114/pdia.2014.44011. Harvard Min, Z., Tan, C., Xu, P., and Zhu, W. (2014). Letter to the EditorConfluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 31(5), pp.335-337. https://doi.org/10.5114/pdia.2014.44011 MLA Min, Zhong-Sheng et al. "Letter to the EditorConfluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques." Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, vol. 31, no. 5, 2014, pp. 335-337. doi:10.5114/pdia.2014.44011. Vancouver Min Z, Tan C, Xu P, Zhu W. Letter to the EditorConfluent and reticulated papillomatosis manifested as vertically rippled and keratotic plaques. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2014;31(5):335-337. doi:10.5114/pdia.2014.44011.

Serial photography and Wood's light examination as an aid to the clinical diagnosis of dermatitis artefacta

A patient is described with dermatitis artefacta, which is a common psychocutaneous disorder whereby a fully-aware patient self-inflicts injury to their skin. The motives for their behaviour can vary and the patient always tries to hide the responsibilities for their actions.In this case report, serial use of standardised photography provided strong evidence to support the diagnosis of dermatitis artefacta. The fluorescent properties of Trimovate® Cream under Wood's light examination corroborated the diagnosis. Trimovate® Cream was applied to the skin surrounding the injuries and the limb was occluded with four layers of bandages. Traces of Trimovate® Cream were seen under Wood's light on the outer layers of the bandage. This suggested transfer of the cream from the occluded skin surface by the patient's fingers whilst tampering with the dressings.This case report shows how serial photography and imaging using ultraviolet (UV) fluorescence can provide evidence to support the diagnosis of dermatitis artefacta.

Agminated Acquired Melanocytic Nevi of the Common and Dysplastic Type

Dear Editor: 'Agminated' refers to circumscribed grouping of lesions confined to a localized area of the body. Pigmented lesions that have been described as agminated includes melanocytic nevi1, Spitz nevi2, nevi spilus3, blue nevi4, and multiple lentigines5. However, the presence of acquired common and dysplastic nevi (ACDN) arranged in an agminated pattern has not been well-established. Herein, we describe a patient with multiple agminated acquired melanocytic nevi, several of that were histologically characterized as dysplastic nevi. A 16-years-old female presented with multiple irregular moles on her right inguinal area (Fig. 1A). Her parents reported that this cluster of nevi developed at the age of 6 years, and continuously increased in numbers and sizes. No family history of melanoma or multiple moles was present. Physical examinations revealed more than 40 melanocytic nevi clustered in a 5×5 cm skin area on her right inguinal area, where several of these nevi were irregular with variegation of color and a diameter greater than 5 mm (Fig. 1A). No background pigmentation within or surrounding the cluster was noted clinically or even with Wood's light examination. Dermoscopy of the clustered nevi revealed a diffuse patchy reticulation (Fig. 1B). A biopsy from a clinically atypical nevus demonstrated a lentiginous, compound-melanocytic nevus with architectural disorder in the epidermis. In the dermoepidermal junction, the nests of nevus cells were profused in the tips and sides of elongated rete ridges. In the center of the nevus, nests of melanocytes are present in the papillary dermis (Fig. 2A). There were scattered single cells in a lentiginous array without continuous proliferations (Fig. 2A). A few atypical melanocytes with large, irregularly shaped, hyperchromatic nuclei lay individually or within a small group (Fig. 2B). The diagnosis of dysplastic nevi was confirmed by the presence of an architectural disorders and cytologic atypia. Several nevi within the cluster had clinical, dermoscopic, and histologic features which are commonly attributed to dysplastic nevi. Fig. 1 (A) Asymmetric, multiple, grouped, irregular, flat, dark brownish papules and macules on the inguinal area. (B) Dermoscopic features showing a patchy reticulated network. Fig. 2 (A) There was elongation of rete ridges and increase in the number of junctional melanocytes, arranged in a nest. In the dermoepidermal junction, nests of nevus cells were profused on the tips and sides of elongated rete ridges. There were also scattered ... Dysplastic nevi have been the subject of ongoing controversy regarding its definition and use of more than 20 years6. It is argued that dysplastic nevi are both acquired and common, and they should be regarded as nothing but common nevi. However, when considering a review article from Elder6, theses lesions have been only significant in relation to melanoma, as stimulants of melanoma, as markers of risks for melanoma, and as potential and occasional actual precursors of melanoma. Therefore, clinical and histological classifications of nevi have the most important purpose of categorizing these lesions so that dysplastic nevi can be distinguished, clinically and histologically, from melanoma. In our patient, the diagnosis of dysplastic nevi was based on the clinical, dermoscopic and histologic features. Agminated dysplastic lesions, similar to our case should be distinguished from other forms of dysplastic nevi, which show a segmental distribution without a definite clustering. Two cases of dysplastic nevi with segmental distributions have been previously reported in the literature7,8. Both of the cases are not being described as agminated, because multiple dysplastic nevi were distributed throughout the patients' upper left quadrant. One thing that deserves the attention of clinicians is that malignant melanoma developed within the lesions of both cases. There still exists much controversy about the presence of agminated ACDN. Marghoob et al.9 and Bragg et al.10 previously reported 5 cases of agminated ACDN. Unlike our case, however, agminated lesions were superimposed on an underlying dysplastic nevus syndrome phenotype in 4 out of 5 cases. In the 2 cases of the 5 reported as agminated ACDN, malignant melanoma did not developed within the agminated lesion, but within the underlying dysplastic nevus syndrome phenotype. The authors believed that agminated ACDN were a new, previously not described, clinical variant of dysplastic nevi. In conclusion, the uncertainty in the biological behaviors of agminated ACDN suggests a strict follow-up for this unusual entity.

Lifa Disease: Frictional Dermal Melanosis over Bony Prominences (Clinicopathological Study)

Background: Lifa disease (Frictional dermal melanosis over bony prominences) has been described in Iraq for the first time in 1993, as a new distinctive pigmentary skin condition that followed chronic friction with a body washing agent (lifa) during bathing. Objective: To assess this increasingly common problem where still many doctors unaware about its presence especially in other Middle East countries. Patients and Methods: A case series descriptive study done in Departments of Dermatology-Najaf and Baghdad Teaching Hospitals, between March 2007- Oct.2008. Full history and clinical examination were done for all patients including Wood's light examination. Biopsies were taken from 21 patients and sent for hematoxylin-eosin and Congo red stains. Results: Fifty two (49 female and 3 male) patients with typical clinical features of lifa disease were studied. The mean age of presentation was 27.92 ± 7.58 years. All patients were slim with prominent bones and low body mass index, used lifa vigorously during bathing.Pigmentation was distributed bilaterally and symmetrically over bony prominences. The most common affected sites were: clavicular areas (67.3%) and upper back (42%). Wood's light and histopathological examinations revealed dermal melanosis. No amyloid deposit was detected by using Congo red stain in any patient. Conclusions: Lifa disease is a common distinctive pigmentary disfiguring problem especially among females. The histopathology showed dermal melanosis, and might be confused with other pigmentary problems like macular amyloidosis.

Induction of Vitiligo-Like Hypopigmentation after Imiquimod Treatment of Extramammary Paget's Disease

Dear Editor: Imiquimod 5% cream, an immune response modifier, is licensed for the treatment of extramammary Paget's disea se (EMPD). Although pigmentary changes associated with imiquimod treatment have been listed as possible side effects on the package insert, the reports are rare and sometimes inconsistent in the dermatology literature. Some studies described vitiligo-like hypopigmentation, while other studies reported hyperpigmentation after imiquimod use1. In our skin cancer clinic, we frequently applied imiquimod 5% cream every other night for 6~8 hours in EMPD patients who are poor surgical candidates or susceptible to local recurrence after surgery. After reviewing the clinical course of three male patients with EMPD, we found that whole skin lesions around scrotum applied with imiquimod were completely depigmented after 3 months in all cases (Fig. 1). The depigmentation did not extend beyond treatment area and affect other vitiligo-prone areas at all. Despite discontinuation of imiquimod, the hypopigmentation did not improve at all after at least 13 months follow-up in all cases. Imiquimod was the only product used and our patients did not have a history of vitiligo at all. Wood light examination shows an accentuation of the pigment loss, and H&E and Fontana Masson reveal decreased pigmentation in the basal layer of epidermis (Fig. 2). The average number of melanocytes in the basal layer counted by 3,4-dihydroxyphenylalanine staining and immunohistochemistry method using HMB-45 antibody was also significantly decreased (Fig. 3). Interestingly, two of our patients had experienced irritiation several times after cryotherapy and podophylline application before imiquimod treatment without inducing any depigmentation, respectively. This supports the likelihood that imiquimod may have caused the vitiligo-like hypopigmentation by a mechanism other than simple irritation. Several possible mechanisms could explain this hypopigmentation. Imiquimod binds to the Toll-like receptors (TLR) 7 and 8 which are cell-surface receptors recognizing ligands associated with pathogenic organisms. TLR-7 activates the T-helper (Th) 1 response and increases the production of pro-inflammatory cytokines mainly interferon-α, tumor necrosis factor-α and interleukin (IL)-12, all of which play a role in the pathogenesis of vitiligo2. The stimulation of the Th1 pathway also results in a predominantly perilesional CD4+ T cell infiltrate and many CD8+ T cells. The CD4+ cells are stimulated by IL-12 to produce IFN-α and IL-2. In addition, imiquimod promotes secretion of IL-6, IL-8, and IL-10, which are pro-inflammatory and pro-apoptosis cytokines that can also cause vitiligo3,4. A previous case report stated that a trial with macrolide immunomodulators could benefit patients, although lacking sufficient evidence5. Expanded use of imiquimod may increase localized depigmentation as observed in our case. Since patients could be emotionally sensitive to the depigmentation of pubic areas, we believe that dermatologists should be aware of this annoying side effect, particularly when using imiquimod on EMPD. Fig. 1 (A) Extramammary Paget's disease lesions around pubic area. (B) Relatively well defined whitish depigmented patches on the imiquimod application sites after 3 months. Fig. 2 The basal layer of epidermis shows no pigmentation (A) at a low magnification view (H&E stain, ×100), and (B) a high magnification view (×400). The basal layer of epidermis shows negative reaction for (C) Fontana-Masson staining ... Fig. 3 Melanocytes in the basal layer of epidermis stained by immunohistochemistry methods using (A) HMB-45 (×400) antibody, and (B) 3,4-dihydroxyphenylalanine staining (×400) were rarely observed in the depigmented lesions.