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Background: Bullous pemphigoid (BP) is an acquired subepidermal autoimmune blistering disease in which there are humoral and cellular responses against the BP180 and BP230 antigens. Dipeptidyl peptidase (DPP)-4 inhibitors enhance endogenous glucagon peptide-1 and glucose-dependent insulinotropic polypeptide secretion with food intake, which leads to insulin secretion, as well as to the reduction of glucagon secretion. Recently, several cases of DPP-4 inhibitor-associated BP have been reported. Objectives: To report 3 cases of DPP-4 inhibitor-associated BP, one of which is due to linagliptin use, as well as to review all currently published cases of DPP-4 inhibitor-associated BP. Case Reports: Three patients diagnosed with BP at our department showed a clear temporal relationship between the introduction of DPP-4 for the treatment of diabetes and the onset of BP. One case was due to linagliptin use, while the other 2 cases were due to an association with vildagliptin-metformin use. Conclusions: This is the first report of linagliptin-associated BP. Furthermore, 2 other cases of vildagliptin-associated BP are reported.

Case Reports; Journal Article; Local flaps are the standard procedure to reconstruct facial defects. As it occurs in any surgical procedure, the incision should be planned so that scars are located in the minimum skin tension lines. We report two cases of O to Z flaps in the supra and infraciliary regions. One of them is a hatchet flap. Yes

Resumen Introduccion y objetivos La psoriasis es una enfermedad inflamatoria cutanea de naturaleza inmunologica mediada por citoquinas de tipo Th1. El tratamiento con anticuerpos anti-factor de necrosis tumoral α (TNF-α) (infliximab) ha proporcionado respuestas clinicas significativas; sin embargo, los mecanismos implicados en la curacion no estan bien aclarados. El objetivo del presente trabajo es evaluar las variaciones de la histologia y en la expresion de marcadores de proliferacion y apoptosis, en biopsias cutaneas secuenciales de pacientes con psoriasis tratados con in fliximab. Material y metodos Se estudiaron biopsias de piel (sana y lesionada) de 3 pacientes afectados de psoriasis generalizada moderada-grave (indice de area y gravedad de la soriasis [PASI]: 35 de media) tratados con infusiones por via intravenosa de infliximab (5 mg/kg) en las semanas 0, 2 y 6. Las biopsias se realizaron en los dias 0, 14 y 28, y fueron procesadas para estudio histologico convencional e inmunohistoquimico con marcadores de apoptosis –TP53, BCL-2 y anticaspasas 3 y 8–y de proliferacion celular –Ki67–. Resultados El tratamiento con infliximab se asocio con una significativa mejoria clinica en los 3 pacientes (PASI medio: 21,6 a los 14 dias y 13,9 a las 6 semanas), que se correlaciono con la desaparicion progresiva de las lesiones histologicas, con disminucion de la proliferacion epidermica. Sin embargo, no observamos imagenes de apoptosis ni obtuvimos positividad con los anticuerpos anticaspasas. La expresion de TP53 disminuyo a las 2 semanas del inicio del tratamiento, siendo similar a la piel normal a los 28 dias. Conclusiones La respuesta clinica e histologica de la psoriasis con infliximab no se asocio a un incremento significativo en los marcadores de apoptosis evaluados.

Background and objectives Psoriasis is an inflammatory skin disease of immunologic nature that is mediated by T-helper-1 cytokines. Clinical response to treatment with antitumor necrosis factor (TNF) a antibodies (infliximab) has been significant; however, the mechanisms for clearance of lesions have not been elucidated. The aim of the present study was to assess variations in the histology and expression of proliferation and apoptotic markers in sequential skin biopsies of patients with psoriasis treated with infliximab. Material and methods We studied skin biopsies (of lesioned and healthy skin) from 3 patients with extensive moderate-to-severe psoriasis (mean psoriasis area and severity index [PASI] score, 35) treated with intravenous infliximab infusions (5 mg/kg) at weeks 0, 2, and 6. Biopsies were taken on days 0, 14, and 28, and were processed for conventional histological and immunohistochemical study. The apoptotic markers used were TP53, B-cell lymphoma 2 protein, anticaspase 3, and anticaspase 8. The cell proliferation marker used was Ki67. Results Treatment with infliximab was associated with a significant clinical improvement in 3 patients (mean PASI score, 21.6 at 14 days and 13.9 at 6 weeks), which correlated with the progressive disappearance of histological lesions with a decrease in epidermal proliferation. However, apoptosis was not observed, and the samples tested negative for anticaspase antibodies. Expression of TP53 decreased 2 weeks after starting treatment, and was similar to that in normal skin at 28 days. Conclusions Clinical and histological response of psoriasis to infliximab was not associated with a significant increase in the apoptotic markers assessed.

La Organizacion Mundial de la Salud define la adolescencia como el periodo comprendido entre los 10 y los 19 anos de edad, durante el cual se producen cambios fisicos, psicologicos y conductuales. En esos anos, los adolescentes adquieren nuevos habitos que pueden favorecer el contacto con diversos alergenos que antes estaban restringidos a adultos, como, por ejemplo, cosmeticos, piercing y tatuajes1. Ademas de estos nuevos habitos, los adolescentes que padecieron alguna dermatosis durante su infancia, como dermatitis atopica, son mas susceptibles a posibles sensibilizaciones, facilitadas por haber tenido alterada la barrera cutanea o haber estado en contacto con tratamientos topicos, que son potenciales alergenos2. La informacion de que disponemos acerca de la incidencia y de la prevalencia de dermatitis alergica de contacto (DAC) entre los adolescentes es muy escasa3. En la decada de los noventa, la mayoria de las publicaciones fueron series de casos de ninos y adolescentes con DAC o estudios en ninos y adolescentes con sospecha de DAC. Existen muy pocos estudios en que se haya realizado pruebas epicutaneas a poblaciones de adolescentes no seleccionadas por su enfermedad4-6 y que valoren en ellos la relevancia de las positividades de estos tests, para asi poder hacer una estimacion real de la prevalencia de DAC en este grupo etario. Tampoco existen estudios de seguimiento adecuado que valoren la incidencia3. Tanto la dermatitis irritativa como la dermatitis alergica de contacto ocurren durante la infancia y la adolescencia. En general los alergenos de contacto mas comunes en adolescentes son los mismos que en los adultos, aunque hay diferencias de un pais a otro debido a la distinta exposicion a los alergenos7.

Trichothiodystrophy comprises a heterogeneous group of autosomal recessive entities. This fact gives rise to different interrelated neuroectodermal disorders. From a structural point of view these features are the result of the low tissue sulfur content. We report a case of trichothiodystrophy initially classified as Tay syndrome that based on clinical features, complementary exams as well as on the disease evolution was labelled as PIBIDS syndrome.

Trichothiodystrophy comprises a heterogeneous group of autosomal recessive entities. This fact gives rise to different interrelated neuroectodermal disorders. From a structural point of view these features are the result of the low tissue sulfur content. We report a case of trichothiodystrophy initially classified as Tay syndrome that based on clinical features, complementary exams as well as on the disease evolution was labelled as PIBIDS syndrome.

Case report The Leishmania genus is formed by parasitic protozoa which are transmitted by the bite of infected female sand flies. Cases of sexual, vertical or transfusional transmission or via infected needles have also been described. In humans, 4 forms of this disease have been described: localised cutaneous (LC), diffuse cutaneous, mucocutaneous and visceral (1). LC counts for 50–75% of all cases (2), it is the mildest form of the disease and can be caused by any species of Leishmania. In Spain, the most frequent form is the oriental sore caused by L. infantum (2). Most cases resolve spontaneously within one year. In United States and Europe, the incidence is increasing due to tourism and co-infection with HIV. The morphological spectrum of LC is very wide; multiple forms of clinical presentation have been described, although the most characteristic one is the nodular ulcerative lesion, characterised by painless crater-like ulcers with a necrotic base and covered by an adhesive crust. The main complication of LC is its progression in some strains towards the other 3 forms of the disease (3). In patients with AIDS and other diseases associated with immunosuppression the risk of dissemination is much higher than in the immunocompetent. We present a case of LC with clinical and histopathological features similar to a pyogenic granuloma. Yes

Case Reports; Journal Article; Review; Superficial Acral Fibromyxoma is a rare tumor of soft tissues. It is a relatively new entity described in 2001 by Fetsch et al. It probably represents a fibrohistiocytic tumor with less than 170 described cases. We bring a new case of SAF on the 5th toe of the right foot, in a 43-year-old woman. After surgical excision with safety margins which included the nail apparatus, it has not recurred (22 months of follow up). We carried out a review of the location of all SAF published up to the present day. Yes

Baboon syndrome was first described as a particular type of systemic contact dermatitis, characterized by an exanthem with involvement of the buttocks and flexures. In children, it is an important entity to take into account for the differential diagnosis of viral exanthem. A large number of allergens have been implicated, although inhalation of mercury vapor is a common trigger. We present the findings in 14 patients younger than 14 years with baboon syndrome. We also look at the frequency in children and the most common causes and triggers in our area.

El sindrome de Wells o celulitis eosinofilica consiste en una dermatosis inflamatoria poco frecuente, de etiologia desconocida, con manifestaciones clinicas variadas e histologia caracteristica, aunque no patognomonica, que habitualmente presenta un curso recidivante y una inconstante respuesta al tratamiento. Pertenece a las dermatosis eosinofilicas un amplio grupo de trastornos caracterizados por la presencia de eosinofilos en el infiltrado inflamatorio1. Por otro lado, el sindrome de Churg-Strauss se ha incluido tradicionalmente dentro del grupo de las vasculitis de pequeno vaso, siendo los elementos claves para su diagnostico la existencia de asma, eosinofilia en sangre periferica y tejidos, vasculitis necrotizante y granulomas extravasculares2. La relacion del sindrome de Wells con el sindrome de Churg-Strauss u otros sindromes hipereosinofilicos sistemicos, como el sindrome hipereosinofilico, es controvertida. Algunos autores defienden la existencia de una patogenia comun y otros que, en lugar de tratarse de entidades diferentes, se deberian considerar como diferentes expresiones de una misma enfermedad3. Presentamos el caso de una paciente con criterios clinicos e histologicos de sindrome de Wells en el contexto de un sindrome de Churg-Strauss no previamente diagnosticado.

Background Androgenetic alopecia (AGA) is the most frequent cause of hair loss affecting up to 50% of men and 40% of women by the age of 50. Methods This paper outlines the current status of diagnosis and offers guidelines for optimal management of AGA in both men and women. Results The diagnosis of AGA can usually be confirmed by medical history and physical examination alone. A trichogram can be useful to assess the progression of the hair loss. A scalp biospy is diagnostic but usually not required. In women with signs of hyperandrogenism, investigation for ovarian (polycystic ovarian disease) or adrenal (late-onset congenital adrenal hyperplasia) disorders is required. Mild to moderate AGA in men can be treated with oral finasteride or topical minoxidil. Oral finasteride at the dosage of 1 mg/day produced clinical improvement in up to 66% of patients treated for 2 years. The drug is effective for both frontal and vertex hair thinning. Medical treatment with finasteride or minoxidil should be continued indefinitely since interruption of therapy leads to hair loss with return to pretreatment status. Mild to moderate AGA in women can be treated with oral antiandrogens (cyproterone acetate, spironolactone) and/or topical minoxidil with good results in many cases. Hair systems and surgery may be considered for selected cases of severe AGA both in men and in women. Conclusions Patients with AGA should be informed about the pathogenesis of the condition. If used correctly, available medical treatments arrest progression of the disease and reverse miniaturization in most patients with mild to moderate AGA.

Background Alopecia areata (AA) occurs with the apparition of asyntomatic non inflamatory alopecia plaques without scars. We distinguish several variants which are divided into two groups: typical forms (AA in single or multiple plaques) and atypical forms (by its presentation, evolution or paradoxical regrowth). Objetives and methods We describe the cases of AA treated in our Trichology Unit between January 2000 and December 2011. Results We obtained 488 cases of AA. 114 (23.36%) were unusual form of AA or had paradoxical regrowth. The most common unusual form of AA was sisaipho type (7.37%), followed by AA for black and blonde hair (5.32%), atypical diffuse forms (4.30%), androgenetic alopecia type and (3.89%) and AA rectangular occipital (0.68%). Furthermore, we found nine cases of paradoxical regrowth (1.84%). Conclusions Atypical variants of AA in our series are less than 25% of all cases, although it should be noted that since it is a specialized unit, we may be making a selection bias to be more difficult to diagnose cases or poor outcome. Received: 29 May 2013; Accepted: 24 July 2013

Tuberculosis can cause genital ulcers, although this clinical manifestation was more frequent at the beginning of the 20th century as it was related to the rite of circumcision. We report the case of a patient with this disease, presumably acquired through sexual intercourse.

growth factor and its receptor mRNA in angiosarcoma. No statistical diVerences were found in serum VEGF Lab Invest 1995; 73: 859–863. levels between the other angiosarcoma patients (cases 2. Masood R, Cai J, Zheng T, Smith L, Naidu Y, Gill PS. 3–11) in whom the p53 gene point mutation was not Vascular endothelial growth factor/vascular permeability detected; these patients include those without metastasis factor is an autocrine growth factor for AIDS-associated (153 ± 70 pgml O 1 , range 65–223, n = 4), those with Kaposi’s sarcoma. Proc Natl Acad Sci USA 1997; 94: metastasis to parotid lymph nodes (166 ± 70 pgml O 1 , 979–984. 3. Naka N, Tomita Y, Nakanishi H, Araki N, Hongyo T, range 62–244, n =6), and those with remote metastasis Ochi T, et al. Mutation of p53 tumor-suppressor gene in (119 ± 101 pgml O 1 , range 7–269, n =7) (Fig. 1). angiosarcoma. Int J Cancer 1997; 71: 952–955. Because of serious heart failure, the patient who had 4. Masuzawa M, Fujimura T, Hamada Y, Fujita Y, Hara H, detectable p53 gene point mutation (case 1) was treated Nishiyama S, et al. Establishment of a human hemangiosarwith local radiation therapy alone. The other patients coma cell line (ISO-HAS). Int J Cancer 1999; 81: 305–308. were treated with surgery, radiation therapy, local or 5. Amo Y, Masuzawa M, Hamada Y, Takasu H, Fujimura T, Katsuoka K, et al. Serum levels of vascular endothelial systemic administration of recombinant interleukin-2 growth factor in a hemangiosarcoma patient with a new(IL-2), and immunotherapy using IL-2 and IL-2typed p53 gene point mutation. Br J Dermatol 2000; 143: activated lymphocytes. The eVect of these treatments 1118–1119. may have contributed to the serum VEGF levels. 6. Amo Y, MasuzawaM, Hamada Y, Katsuoka K. Expression Therefore, serum VEGF levels may not be correlated of vascular endothelial growth factor in a human hemanwith clinical course in most cases of angiosarcomas giosarcoma cell line (ISO-HAS). Arch Dermatol Res 2001; without p53 gene mutation. 293: 296–301. 7. Hollstein M, Sidransky D, Vogelstein B, Harris SR. p53 mutations in human cancers. Science 1991; 253: 49–53. REFERENCES

ejd.2012.1846 Auteur(s) : Ana Rita Rodrigues Barata rita.rodrigues.md@gmail.com, Francisco Camacho-Martinez Department of Dermatology and Venereology, Hospital Universitario Virgen Macarena, Av Dr Fedriani s/n 41009 Sevilla, Spain A 56-year-old woman with no relevant personal or medical history was treated in our dermatology department over a long period for female pattern hair loss. She had been on treatment with finasteride 2.5 mg daily and minoxidil 5% twice daily for several years with a [...]

We report a new case of sarcomatoid carcinoma, which showed cellular features of basal cell carcinoma and malignant fibrous myxoid histiocytoma. For this new case and rare neoplasm, we propose the designation of sarcomatoid basal cell carcinoma, as both components were intimately intermingled, the spindle cells seemed to arise from epithelial cells, and both tumoral components showed the same immunohistochemistry expression, cytokeratin and P53 protein, suggesting a monoclonal origin. The epithelial component, a basal cell carcinoma, may have been the first component in the carcinogenesis process.

ejd.2011.1501 Auteur(s) : Jose Neila drneils@hotmail.com, Lara Ferrandiz, David Moreno-Ramirez, Francisco Camacho Martinez Department of Dermatology, Virgen Macarena University Hospital, Av/ Dr. Fedriani s/n, 41009 Seville, Spain We are witnessing a rise in tuberculosis incidence in developed countries [1]. The HIV epidemic, population migration from high endemic areas, development of antibiotic-resistant strains of Mycobacterium tuberculosis and wider use of immunosuppressive therapies have been [...]

ejd.2011.1451 Auteur(s) : Martina Ales-Fernandez malesfer@hotmail.com, Antonio Rodriguez-Pichardo, Francisco M Camacho-Martinez Department of Dermatology, Virgen Macarena University Hospital, Av/ Dr. Fedriani s/n, 41009 Seville, Spain Calcinosis cutis is an uncommon disorder characterized by deposition of insoluble calcium salts in cutaneous tissues. Depending on their pathophysiogenic mechanisms, they are classified into four types: dystrophic, metastatic, iatrogenic and idiopathic [1]. The [...]

Dr Martino Neumann’s article in the ARCHIVES, “Is Pharmaceutical Sponsorship of a Dermatologic Conference Proper?” 1 raises important, well-established, and obvious issues of concern to all dermatologists as well as physicians in general. The relationship between the pharmaceutical and allied health industries and the medical profession needs constant and careful scrutiny to avoid the potential for compromise of science by commerce. The objectives of both are not mutually exclusive, and no one can ignore the fact that the many excellent therapies available to patients are a credit to the time and finances invested by these industries in research and development of new products. Physicians need to be informed about these products when they become available, and the sharing of this information is part of the legitimate interchange that takes place at every major congress. Needless to say, these exchanges of such information between the conference and satellite symposiums held are obvious and universally accepted.

Actas Dermosifiliogr. 2007;98:372-6 373 To the Editor: We describe a 57-year-old man with multiple basal cell carcinomas on the scalp, where he had undergone radiation therapy in childhood. He consulted for a pearly mass adjacent to a violaceous mass of 5 cm that was poorly defined, indurated, asymptomatic, and with several peripheral nodules (Figure 1), but no local or regional lymph node enlargement. The biopsy showed a basal cell carcinoma and a highly malignant angiosarcoma, with mixed epithelioid and fusiform cell type, high mitotic index, and considerable vascular invasion (Figure 2). Immunohistochemistry showed strong positivity for CD31 (Figure 3), partial for cytokeratins, and low for CD34 and VIII antigen. The computed tomography scans and magnetic resonance imaging revealed infiltration of the subcutaneous cellular tissue and a lesion in the left frontoparietal lobe, the nature of which could not be determined, as the patient declined angiography. Biopsies of the underlying bone and cerebral parenchyma showed no evidence of infiltration. Surgery and local radiation therapy were performed. However, at 2 months, new nodules appeared on the scalp as well as enlarged retroauricular lymph nodes; these were treated by local radiation therapy. Pulmonary metastases have appeared recently, and the patient is undergoing systemic chemotherapy at the time of writing. Angiosarcoma is a rare malignant tumor. A third of these tumors occur in the skin, with a predisposition for superficial soft tissues.1 The condition is more common in older white men. Lymphedema, chronic radiodermatitis, and immunosuppression are related factors. The pathogenesis is unknown, although it appears to have a multifocal origin in the lymphatic vessels. As occurs with basal cell carcinomas, gene mutations have been found in the gene for p53, which would induce overexpression of vascular endothelial growth factor.2,3 Angiosarcoma can display 4 clinical presentations: idiopathic angiosarcoma of the scalp and face, angiosarcoma associated with chronic lymphedema, angiosarcoma secondary to radiation therapy, and primary angiosarcoma of the breast. Initially, all of these types Radiotherapy-Induced Scalp Angiosarcoma

Journal Article; INTRODUCTION Frontal fibrosing alopecia (FFA) in an entity characterized by the recession of the frontotemporal hairline (FTHL) with alopecic scarring change. In recent years there are numerous articles discussing the usefulness of dermoscopy for the clinical diagnosis of different types of scarring alopecia. MATERIALS AND METHODS We value 79 patients diagnosed with FFA, evaluating some trichoscopical findings described as typical for FFA: Absence of follicular opening, follicular hyperkeratosis, follicular plugs and erythema. RESULTS In a population of 79 women, 100% showed no follicular opening, 72.1% follicular hyperkeratosis, 66.3% perifollicular erythema and 44.8% follicular plugs. Thus, 100% of patients had at least one of the dermoscopic elements described as suggestive of FFA, 53% two of them, 45% three and 27%, all those elements. Perifollicular erythema was present in 95% of cases in which the disease was active. CONCLUSIONS We consider that the presence of perifollicular erythema will be a direct marker of FFA activity. Yes

Objectives: To evaluate topical bimatoprost for eyelash growth in patients with alopecia areata (AA). Design: A 1-year retrospective study, bilateral eyelash alopecia. Materials and Methods: Forty-one subjects with AA universalis without ocular disease applied 0.03% bimatoprost to the eyelid margin once a day over the course of 1 year. Results: Thirty-seven subjects completed the study, one patient was eliminated due to conjunctivitis at the beginning of treatment, two patients developed conjunctivitis after 6 months of treatment, and a fourth did not follow directions. Researchers evaluated patients’ eyelash growth every 4 months. We observed complete growth in 24.32%, moderate growth in 18.91%, slight growth in 27.02% and without response in 29.72%. Conclusion: Bimatoprost may be effective and safe in the treatment of eyelash AA. 43.24% of the patients had an acceptable cosmetic response (total and moderate growth). Limitations: Design without control.