Papular Acantholytic Dyskeratosis of the Vulva: A Case Report and Literature Review

Nawara Sakpuwadol, Poonkiat Suchonwanit Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Poonkiat Suchonwanit, Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand, Tel +66-2-2011141, Fax +66-2-201-1211 Ext 4, Email [email protected]: Papular acantholytic dyskeratosis (PAD) of the vulva is an uncommon benign condition characterized by multiple hyperkeratotic papules in the anogenital region. First described in 1984, PAD belongs to the spectrum of focal acantholytic dyskeratoses and shares histopathological features with Darier disease and Hailey-Hailey disease. Despite its persistence, PAD is benign, requiring only reassurance in many cases. However, various treatment modalities have been reported for symptomatic patients, including topical and systemic therapies, and procedural interventions. We present a case of a 21-year-old Thai woman with asymptomatic perivulvar papules with typical histopathological features of PAD. After conservative management, the patient remained asymptomatic during follow-up. Additionally, we present a review of the current literature on this uncommon entity. This case highlights the importance of clinicopathological correlation in diagnosing PAD and distinguishing it from other clinically similar disorders. We discuss the clinical presentation, histopathological features, differential diagnosis, potential genetic associations, and management options for PAD.Keywords: benign tumor, Darier disease, focal acantholytic dyskeratosis, genetic, genital papule, Hailey-Hailey diseas

Hyperglycemia Is a Potential Prognostic Factor for Exacerbation in Severe Psoriasis with Diabetes or Prediabetes

Tanat Yongpisarn,1 Kunlawat Thadanipon,1,2 Poonkiat Suchonwanit,1 Ploysyne Rattanakaemakorn1 1Division of Dermatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Ploysyne Rattanakaemakorn, Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand, Tel +662-201-1141, Fax +662-201-1211, Email [email protected]: Psoriasis is an immune-mediated skin disease with a chronic relapsing-remitting course. Hyperglycemia has been shown to correlate with psoriasis severity. However, whether it could trigger psoriasis flares is not known.Objective: To investigate the association between hyperglycemia and psoriasis exacerbation.Methods: We conducted a retrospective cohort study at a university-affiliated hospital in Bangkok, Thailand, between 2008 and 2022 to examine the effects of elevated HbA1c on psoriasis flares. Patients with psoriasis vulgaris and either type 2 diabetes mellitus (T2DM) or impaired fasting glucose (IFG) who had at least 2 HbA1c values were identified. Statistical analyses were performed using mixed-effects logistic regression.Results: A total of 201 psoriasis patients (95 with severe psoriasis and 106 with mild psoriasis) with 1,717 follow-up visits were included in the analysis. In patients with severe psoriasis, HbA1c ≥ 7% (adjusted odds ratio (OR): 1.905 (95% confidence interval: 1.328– 2.731)) and alcohol consumption status (adjusted OR: 3.328 (1.235– 8.965)) were identified as independent prognostic factors for psoriasis flares. Meanwhile, in mild psoriasis patients, none of the variables were independently associated with psoriasis flares.Conclusion: Hyperglycemia and alcohol consumption were associated with exacerbation in patients with severe psoriasis who had T2DM/IFG.Plain Language Summary: Certain environmental factors, such as infections and medications, can cause psoriasis flare-ups. Research suggests that psoriasis-induced inflammation can trigger insulin resistance and high blood sugar (hyperglycemia), which in turn triggers abnormal functioning of the blood vessel’s inner lining, ultimately leading to atherosclerosis and cardiovascular disease. Interestingly, insulin resistance may also worsen psoriatic skin lesions. Multiple studies have found a correlation between psoriasis severity and hemoglobin A1C (HbA1c, average blood sugar levels for the last 3 months); however, it is unknown whether hyperglycemia can also cause psoriasis exacerbation. We aimed to explore the potential of hyperglycemia as a predictor of psoriasis flare-ups. Our study highlights the importance of managing diabetes and psoriasis concurrently to improve the health outcomes of psoriasis patients. Patients with severe psoriasis and diabetes or prediabetes with high blood sugar (HbA1c ≥ 7%) or a history of alcohol consumption are at higher risk of exacerbation. Diabetes monitoring is required for all psoriasis patients, and strict glycemic control may aid in the management of psoriasis.Keywords: psoriasis, diabetes mellitus type 2, impaired fasting glucose, prognosis, exacerbatio

Statement from the frontal fibrosing alopecia international expert alliance: SOFFIA 2024

Background As the incidence of frontal fibrosing alopecia (FFA) continues to rise, there is a need for an optimal treatment algorithm for FFA. Objective To produce an international consensus statement on the treatment modalities and prognostic indicators of FFA. Methods Sixty-nine hair experts from six continents were invited to participate in a three-round Delphi process. The final stage was held as a virtual meeting facilitated via Zoom. The consensus threshold was set at ≥66%. Results Of 365 questions, expert consensus was achieved in 204 (56%) questions following completion of the three rounds. Three additional questions were included at the final meeting. The category with the strongest consensus agreement was disease monitoring (9; 100%). Questions pertaining to physical therapies achieved the least category consensus (15; 40%), followed by systemic therapy (45; 43%). Limitations The study lacked sufficient representation from Africa and South America. Conclusion SOFFIA highlights areas of agreement and disagreement among experts. Robust research is warranted to provide evidence-based treatment recommendations

Role of janus kinase inhibitors in the treatment of alopecia areata

Korn Triyangkulsri, Poonkiat Suchonwanit Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Abstract: Alopecia areata (AA) is a common hair loss disorder worldwide with characteristic exclamation mark hairs. Although AA is self-limited, it can last for several months or even years in some patients. Currently, there is no US Food and Drug Administration-approved treatment for AA. Many off-label treatments are available but with limited efficacy. Through a better understanding of molecular biology, many targeted therapies have emerged as new alternatives for various autoimmune diseases. Various janus kinase (JAK) and signal transducer and activator of transcription (STAT) proteins form signaling pathways, which transmit extracellular cytokine signals to the nucleus and induce DNA transcriptions. By inhibiting JAK, T-cell-mediated inflammatory responses are suppressed. Increasing evidence suggests that JAK inhibitors (JAKis) are effective in the treatment of many autoimmune diseases, including AA. Among these, several studies on tofacitinib, ruxolitinib, and baricitinib in AA had been published, demonstrating promising outcomes of these agents. Unlike oral formulations, efficacy of topical forms of tofacitinib and ruxolitinib reported in these studies is still unsatisfactory and requires improvement. This review aims to summarize evidence of the efficacy and safety of JAKis in the treatment of AA. Keywords: baricitinib, JAK, JAK inhibitors, JAK-STAT pathway, ruxolitinib, tofacitini

Parietal scalp is another affected area in female pattern hair loss: an analysis of hair density and hair diameter

Salinee Rojhirunsakool, Poonkiat Suchonwanit Department of Medicine, Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Purpose: Female pattern hair loss (FPHL) is a common hair disease. However, studies of the quantitative measurement of FPHL are still limited. The aim of this study was to investigate the characteristics of hair density and hair diameter in normal women and FPHL patients, and further correlate the quantitative measurement with the clinical presentation of FPHL.Patients and methods: An evaluation of 471 FPHL patients and 236 normal women was carried out according to the Ludwig classification, and analysis was performed by using a computerized handheld USB camera with computer-assisted software. Various areas of the scalp, including frontal, parietal, midscalp, and occipital, were analyzed for hair density, non-vellus hair diameter, and percentage of miniaturized hair.Results: The hair density in normal women was the highest and the lowest in the midscalp and parietal areas, respectively. The FPHL group revealed the lowest hair density in the parietal area. Significant differences in hair density, non-vellus hair diameter, and percentage of miniaturized hair between the normal and FPHL groups were observed, especially in the midscalp and parietal areas.Conclusion: The parietal area is another important affected area in FPHL in addition to the midscalp area. This finding provides novel important information of FPHL and will be useful for hair transplant surgeons choosing the optimal donor sites for hair transplantation in women. Keywords: androgenetic alopecia, alopecia, phototrichogram, miniaturizatio

Therapeutic potential of bimatoprost for the treatment of eyebrow hypotrichosis

Nongsak Chanasumon, Tueboon Sriphojanart, Poonkiat Suchonwanit Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Abstract: Eyebrows serve as a key feature of the face and have many roles, including cosmetic appearance and social communication. Eyebrow hypotrichosis, which refers to reduction or absence of the eyebrow hair, could be a major problem that leads to negative functional, psychological, and social consequences. Bimatoprost is an ophthalmic prostamide analog that is approved by the United States Food and Drug Administration for the treatment of eyelash hypotrichosis. Its proposed mechanism is stimulation of the prostaglandin receptor in dermal papilla and melanocyte, thus leading to a prolonged anagen phase and increased melanogenesis. The hair follicle then increases in thickness, length, and darkness. The efficacy of bimatoprost for the treatment of eyebrow hypotrichosis has been supported by well-controlled studies. Bimatoprost, which is noninvasive, effective, and well tolerated, is worth considering as a treatment option for eyebrow hypotrichosis. Keywords: bimatoprost, eyebrow, hair, hypotrichosis, prostaglandin, prostamide&nbsp

Lichen Sclerosus of the Labial Mucosa: A Case Report and Literature Review

Koramon Phuwaraks, Suthinee Rutnin, Poonkiat Suchonwanit Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Poonkiat Suchonwanit, Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand, Tel +66-2-2011141, Fax +66-2-201-1211 Ext 4, Email [email protected]: Lichen sclerosus (LS) is an uncommon, chronic, inflammatory mucocutaneous disorder found predominantly in females with unknown etiology. It presents as a white sclerotic plaque commonly located on the anogenital area. Extragenital LS is less prevalent, and LS affecting the oral mucosa is extremely rare, with only 39 biopsy-confirmed cases reported in the literature. Due to its several mimicking conditions, histological examination is usually required for a definitive diagnosis, particularly in patients with oral LS. Current evidence-based treatment recommendations for oral LS are unavailable; however, most cases tend to improve after treatment with topical or intralesional corticosteroids. We report a case of a 58-year-old female referred from the otolaryngology department for evaluating an asymptomatic whitish sclerotic plaque on the lower lip mucosa that had existed for 1 year. Following a punch biopsy, the patient was diagnosed with LS of labial mucosa. The condition improved after 2 months of treatment with topical and intralesional corticosteroids. The present case report raises awareness in recognizing oral LS and contributes to knowledge of this rare disorder.Keywords: extragenital lichen sclerosus, lichen sclerosus et atrophicus, lichenoid dermatitis, lip, oral mucosa, sclerosi

Trichoscopic Features of Syphilitic Alopecia and Alopecia Areata: A Comparative Study

Kasama Tejapira, Nawara Sakpuwadol, Cherrin Pomsoong, Yanisa Ratanapokasatit, Poonkiat Suchonwanit Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Poonkiat Suchonwanit, Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand, Tel +66-2-2011141, Fax +66-2-201-1211 ext 4, Email [email protected]: Syphilitic alopecia (SA) and alopecia areata (AA) are two distinct conditions that frequently present diagnostic difficulties, especially when differentiating between them due to their similar clinical presentations. Trichoscopy may help in differential diagnosis, but a comparison between trichoscopic features of SA and AA is yet to be researched.Objective: To compare trichoscopic features between SA and AA and determine their discriminative values.Methods: Electronic medical records and trichoscopic images of patients diagnosed with SA or AA between January 2000 and February 2022 were retrieved. Trichoscopic features were statistically compared, and their discriminative values were demonstrated as sensitivity, specificity, predictive value, likelihood ratio, and area under the receiver operating characteristic curve (AUC).Results: A total of 69 patients were included: 23 SA and 46 AA cases were matched with a 1:2 ratio. Black dots, broken hairs, pigtail hairs, exclamation mark hairs, tapered hairs, angulated hairs, and non-pigmented regrowing hairs were significantly more prevalent in AA than in SA (all P< 0.05), whereas erythematous background was more prevalent in SA than in AA patients (P=0.008). Among the aforementioned trichoscopic features, exclamation mark hairs and non-pigmented regrowing hairs had a high positive likelihood ratio for AA (16.17 and 8.34, respectively); however, only exclamation mark hairs revealed high AUC (AUC=0.816).Conclusion: Despite the presence of several similar trichoscopic features between SA and AA, trichoscopy can aid in distinguishing between the two diseases. Exclamation mark hairs are the only trichoscopic feature that can be used to differentiate patients with clinically suspicious SA from those with AA.Keywords: alopecia areata, alopecia syphilitica, dermoscopy, exclamation mark hairs, syphilis, trichoscop