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Tacrolimus ointment 0.1% in pityriasis alba: An open-label, randomized, placebo-controlled study
Abstract
Pityriasis alba (PA) is a frequent reason for dermatological consultation because of its chronic course, tendency to relapse and aesthetic impact.
In view of its strong association with atopic dermatitis, the objective of this open-label study was to assess the efficacy and safety of tacrolimus ointment in the treatment of PA compared with the efficacy of moisturizers.
The study population consisted of 60 individuals of phototype III or IV according to Fitzpatrick's classification, aged 6-21 years. Patients were randomly assigned to one of two groups. Subjects in group A were instructed to apply tacrolimus ointment 0.1% twice daily, 12 h apart, on all hypopigmented macules. Standard moisturizers with SPF 20 sunscreen were used on all lesions applied at least 30 min apart from the tacrolimus ointment. Subjects in group B used solely the same moisturizers with sunscreen. Hypopigmented areas were evaluated at baseline and weeks 0, 3, 6 and 9 by investigators for scaling, hypopigmentation and pruritus on a scale of 0-3. Patient satisfaction was also recorded on a scale of 0-3. All adverse effects were recorded.
A statistically significant improvement through time, in hypopigmentation, pruritus and scaling was observed in both groups during the course of 9 weeks. Hypopigmentation resolved from a baseline score of 2.38+/-0.64 to 1.15+/-0.54 at week 3, 0.46+/-0.51 at week 6 and 0.00+/-0.00 at week 9 for the group applying tacrolimus ointment 0.1%. The difference in improvement between the two groups was statistically significant on all three assessments for hypopigmentation (P<0.001), and for pruritus on week 6 and 9 assessments (P<0.05). Three patients (11.5%) in the tacrolimus group reported a mild transient sensation of burning. All patients in the tacrolimus group reported they were completely satisfied or just satisfied with the treatment compared with only 50% of patients using the placebo.
Tacrolimus ointment 0.1% appears to be an effective and safe treatment for PA.
... Our hypothesis is in disagreement with several authors who claim that PA is a minor
criterion or symptom of AD, both being the same disease.1,2,4,5,6,19,24-26 ...
... A study has confirmed the
inflammatory origin of PA based on the observation of its response to treatment with
immunomodulators. This study compared the use of tacrolimus and placebo in children with
PA and demonstrated higher levels of repigmentation in those patients who used
tacrolimus.19 ...
Pityriasis alba affects 1% of the world population and about 9.9% of the children in Brazil. However, its etiology remains uncertain.
The objective of the present study was to evaluate the immunoexpression of factor XIIIa in dermal dendrocytes of skin lesions of pityriasis alba.
Twenty patients with pityriasis alba and 20 patients with atopic dermatitis underwent biopsy. The dermal dendrocytes marked by factor XIIIa were counted by means of immunohistochemical analysis.
The mean amount of dermal dendrocytes found in the patients with pityriasis alba was 2, whereas in the patients with atopic dermatitis it was 4, with a statistically significant difference between them. A cutoff point of 3 cells/square inch was established to differentiate pityriasis alba from atopic dermatitis, with 80% sensibility and 90% specificity.
We believe that pityriasis alba and atopic dermatitis should be considered different clinical forms within the spectrum of atopic disease, in which sun radiation plays an important role by modulating the progression of the disease.
... Treatment includes topical application of humectants [1], corticosteroids [10], sunscreens [3], and antiseptics [10]. Recently, immunosuppressors (i.e., tacrolimus, pimecrolimus ) have shown an excellent response in atopic related PA [11, 12]. However, there are no clinical trials confirming its usefulness in endemic PA. ...
... The efficacy of petrolatum was also noticed, but was lower compared to these active drugs. It has been reported that tacrolimus is an effective treatment for atopic-related PA [11]. Therefore, current literature suggests that PA etiology could be mainly inflammatory [2, 9]. ...
Background. Pityriasis alba (PA) is a frequent cause of consultation in tropical areas due to its chronic course, frequent relapses, and notorious hypopigmented lesions in pediatric dark skin populations. Currently, no treatment is widely accepted. Objective. To assess the efficacy of 0.0003% calcitriol and 0.1% tacrolimus ointments compared with placebo in the treatment of endemic PA. Methods. Twenty-eight children aged 3-17 years with 56 symmetrical lesions and phototype IV-V, were randomly assigned to receive the treatments on target lesions on the face. Improvement was evaluated at baseline and 8 weeks later clinically and by digital quantification of the affected area, colorimetry, and transepidermal water loss (TEWL). Results. Tacrolimus and calcitriol ointments induced a mean improvement of 68%, compared to 44% of placebo. We found an elevated TEWL in PA lesions. In the treated plaques, the reduction of the affected area was associated with improvement of pigmentation and TEWL. Conclusions. Calcitriol and tacrolimus induced similar repigmentation in endemic PA lesions. Melanogenic, anti-inflammatory, and barrier defect restoration properties of these drugs may explain these findings.
... 32 It typically has a long-term course, tends to relapse, and may pose a notable aesthetic concern for patients. 60 However, it usually resolves without treatment, though there may be some recurrence at the initial location. Pityriasis alba may be more prominently visible in dry weather, after tanning, and in patients with atopic dermatitis due to a prolonged course. ...
... 64 A randomized controlled clinical trial of tacrolimus ointment 0.1% combined with a standard moisturizer with sun protection factor 20 has shown remarkable results. 60 Thus, calcineurin inhibitors may be preferable for facial PA and for patients with an atopic background. ...
Pityriasis alba (PA) is a localized hypopigmented disorder of childhood with many existing clinical variants. It is more often detected in individuals with a darker complexion but may occur in individuals of all skin types. Atopy, xerosis, and mineral deficiencies are potential risk factors. Sun exposure exacerbates the contrast between normal and lesional skin, making lesions more visible and patients more likely to seek medical attention. Poor cutaneous hydration appears to be a common theme for most risk factors and may help elucidate the pathogenesis of this disorder. The end result of this mechanism is inappropriate melanosis manifesting as hypopigmentation. It must be differentiated from other disorders of hypopigmentation, such as pityriasis versicolor alba, vitiligo, nevus depigmentosus, and nevus anemicus. Alleviation of the various risk factors via patient education on proper skin care and hygiene, use of lubricants and emollients, topical corticosteroid therapy in the presence of inflammation, and the novel administration of topical anti-inflammatory drugs such as calcineurin inhibitors can play a crucial role in promoting remission or resolution.
... Results of a prospective study illustrated tacrolimus (a calcineurin inhibitor) ointment, calcipotriol (a vitamin D analog) cream, or topical steroids on target lesions twice daily led to reduced hypopigmentation at 8 weeks in PA patients [20,23]. Topical calcineurin inhibitors are preferred for facial lesions, as they do not carry the long-term risks of steroid induced atrophy or hypopigmentation [24,25]. In addition to its immunomodulatory effects, tacrolimus has shown to induce tyrosinase activity and expression, resulting in melanin biosynthesis in vitro [26]. ...
Post-inflammatory hypopigmentation is a common acquired pigmentary disorder that is more prominent in skin of color, leading to great cosmetic and psychosocial implications. Often, a diagnosis with a pigmentary disorder can negatively impact an individual’s health-related quality of life and may result in stigma. Although most cases of post-inflammatory hypopigmentation resolve spontaneously over time, a systematic diagnostic approach can help with identifying the underlying etiology and informing treatment strategies. It can be due to cutaneous inflammation, sequelae of inflammatory or infectious dermatoses, or dermatologic procedures. Therefore, a thorough understanding of the epidemiology, patient history, physical exam findings, and clinical features of post-inflammatory hypopigmentation phenomenon can explain the primary cause to providers and allow for patient education. It is also important to understand the various therapeutic approaches available and the efficacy of these options, which will inform providers to choose the appropriate therapy for patients. Although algorithms exist for classifying acquired disorders of hypopigmentation, there are no established algorithms for the diagnosis and treatment of post-inflammatory hypopigmentation, which warrants further exploration and discourse.
... 7 The treatment consists of low-potency topical glucocorticoids (hydrocortisone cream or ointment 1.0% to 2.5%, applied twice daily, is cost effective); however, topical calcineurin inhibitors, such as tacrolimus ointment 0.1% or pimecrolimus cream 1%, and calcipotriene ointment 0.005%, are equally effective when topical glucocorticoids are ineffective or unacceptable due to side effects. 6,[9][10][11][12] Topical calcineurin inhibitors are Food and Drug Administration (FDA) approved for children above 2 years of age. ...
Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.
... Tacrolimus have been reported as a speeding resolution. (7) In exceptionally severe cases psoralen and ultraviolet A light (PUVA) therapy may be considered. ...
... In einer weiteren Studie untersuchten Rigopoulos et al. [197] 60 Patienten im Alter von sechs bis 21 Jahren mit einer Pityriasis alba, die eng mit der Neurodermitis assoziiert ist. Sie verglichen hier die Behandlung von 0,1% Tacrolimus in Kombination mit einem Lichtschutzmittel versus Placebo mit Lichtschutzmittel. ...
Zusammenfassung
Bei dem Krankheitsbild der Neurodermitis handelt es sich um eine chronische oder chronisch‐rezidivierende, nichtkontagiöse, entzündliche Hauterkrankung mit in der Regel starkem Juckreiz. Darüber hinaus besteht ein Risiko für komplizierte Verläufe mit bakteriellen oder viralen Superinfektionen. Sowohl die genetische Prädisposition als auch zahlreiche Auslösefaktoren spielen für die Erstmanifestation und das Auftreten der Erkrankungsschübe eine wichtige Rolle, so dass auch die Therapiekonzepte vielfältig sind. Bei zahlreichen für die Neurodermitis zur Verfügung stehenden Behandlungsoptionen gilt es, in Abstimmung mit den Patienten bzw. Eltern erkrankter Kinder fallorientiert einen optimalen Behandlungsplan aufzustellen, der im Verlauf ggf. erneut angepasst werden muss.
Die vorliegende Kurzfassung der S2k‐Leitlinie gibt einen Überblick über alle bisher zur Verfügung stehenden, evidenzbasierten Diagnoseverfahren und Therapiemöglichkeiten sowie über die entsprechenden Empfehlungen, die durch die an dieser Leitlinie beteiligten Fachgesellschaften und Verbände ausgesprochen werden. Diese Empfehlungen wurden auf der Grundlage der bislang zu dem jeweiligen Verfahren vorliegenden klinisch‐wissenschaftlichen Datenlage, die in der ausführlichen Fassung dieser Leitlinie (unter www.awmf.org und jddg.org ) beschrieben ist, konsentiert.
... Extensive PA has been found to resolve with psoralen-UVA therapy 2 . In recent studies, pimecrolimus cream 1% and tacrolimus ointment 0.1% were proved as effective treatment 5 for typical PA 9,10 . ...
Pityriasis alba (PA) is a common benign disease, characterized by hypopigmented macules or patches on the face, usually seen in children. However, two uncommon variants exist, a pigmenting type and an extensive type. Extensive PA is rare. The lesions tend to be less scaly, more persistent, more generalized, more symmetrical, and more frequently seen over the trunk and less so over the face. We report a child who had extensive PA lesions.
... Moreover, migration of cells treated with tacrolimus is markedly increased (45). Thanks to the effect on melanin synthesis, tacrolimus is effective when applied to hypopigmented areas in the third stage of disease (46). Pimecrolimus, another calcineurin inhibitor, has a comparable effect. ...
Pityriasis alba (PA) is a skin disorder that affects children and adolescents. Although it is common worldwide, its incidence is markedly higher in darker skin phototypes. Its characteristic features include an extended, multistage course and spontaneous remissions and recurrences. Preceded by erythematous changes, patches of hypopigmented skin of up to a few centimeters in diameter appear on the upper body. Pruritus may accompany it. Even though its etiology is unknown, possible reported triggering factors include sunlight, beauty treatments, and microorganisms, among others. Calcineurin inhibitors play the most crucial role in PA pharmacotherapy. PA often coexists with atopic dermatitis and is considered one of its milder forms.
... Emollients can minimize scaling but will not impact hypopigmentation, which may persist for months to years despite control of xerosis and inflammation. A few reports have documented efficacy of TCIs [32,33]. ...
Atopic dermatitis (AD) is one of the most common skin diseases affecting infants and children. A smaller subset of adults has persistent or new-onset AD. AD is characterized by pruritus, erythema, induration, and scale, but these features are also typical of several other conditions that can mimic, coexist with, or complicate AD. These include inflammatory skin conditions, infections, infestations, malignancies, genetic disorders, immunodeficiency disorders, nutritional disorders, graft-versus-host disease, and drug eruptions. Familiarity of the spectrum of these diseases and their distinguishing features is critical for correct and timely diagnosis and optimal treatment.
... Ninguno de estos tratamientos, sin embargo, ha producido resultados satisfactorios ni evitado las recaídas. [12][13][14][15] Rigopoulos y col. administraron por primera vez inhibidores de la calcineurina, en este caso, ungüento de tacrolimus al 0.1%, dada su conocida efectividad en la dermatitis atópica, padecimiento con el que se le vincula. ...
Pityriasis alba is a relatively common condition characterized by hypopigmented plaques that appear most frequently on the faces of prea-dolescent children. It is a benign cosmetic defect that is more prominent, and therefore more problematic, for dark-skinned persons. The cause of pityriasis alba is not known precisely, although it has been associated with atopy, and is thought to be aggravated by xerosis.
... Vitiligo [16] 2. Pyoderma gangrenosa [16] 3. Graft-versus-host disease [16] 4. Psoriasis [16] 5. Alopecia areata [16] 6. Behcet's disease [16] 7. Lupus erythematosus [16] 8. Lichen planus [6] 9. HIV-associated Eosinophilic Folliculitis [21] 10. Crohn's disease [6] 11. Pityriasis alba [24] 12. Contact dermatitis [3] 13. Rosacea [3] Tacrolimus is administered at the dose of 0.03-0.05mg/kg/day as continuous infusion. ...
Tacrolimus was developed for the management of graft rejections when the conventional immunosuppressants were a failure in some patients. This drug was later found to be effective in various dermatological disorders, which had a pathological immune basis. Tacrolimus being an immunomodulator has been found to be effective in immunological skin disorders when applied topically.
Among special therapeutic options, anti-inflammatory treatment using topical glucocorticosteroids (TCS) or topical calcineurin inhibitors (TCI) are core elements. Antimicrobial therapy using preferably antiseptics can help against microbial colonization or infection. Antipruritic therapy includes also systemic antihistamines although with limited evidence. New topical substances include phosphodiesterase inhibitors and opioid receptor antagonists.Phototherapy with UVB or UVA1 is often used. Allergen-specific immunotherapy (ASIT) has no routine place however has been tried successfully in some studies.Greatest progress has been made in new immunomodulatory therapy already beyond immunosuppressives like ciclosporin A, methotrexate, azathioprine, or mycophenolate.Inhibitors of the janus kinase (JAK) are registered, as well as specific biologics like anti-interleukin 4/interleukin 13 (Dupilumab) or interleukin 13 (Tralokinumab). With anti-interleukin 31 (Nemolizumab), new antipruriginous strategies may be possible. Besides pharmacotherapy, also psychosomatic counseling and behavioral therapy have been proven helpful. Few diseases are characterized by the use of so many unconventional procedures like atopic eczema. Most of them have limited or no proven efficacy, but are very popular with the patients. Among “alternative” strategies for phytotherapeutic approaches, acupuncture may be tried. There was no effect in several controlled trials for bioresonance, homeopathy, or kinesiology. There is a high degree of placebo responders in controlled clinical trials in atopic eczema possibly due to a high suggestibility in this disease.KeywordsAnti-inflammatory treatmentTopical glucocorticoidsTopical calcineurin inhibitorsSystemic immunomodulatorsJAK inhibitorsBiologicsDupilumabTralokinumabUnconventional procedures
As we continue to work toward a more equitable future of medicine, it is necessary to recognize the needs distinct to pediatric dermatology to decrease health disparities that affect this patient population. Currently, there is very little research investigating the predominate risk factors and management of pityriasis alba in children with skin of color. Herein, we discuss existing literature on pityriasis alba in children with skin of color, as well as the research and educational needs in this area. J Drugs Dermatol. 2023;22(4) doi:10.36849/JDD.7221 Citation: Hyun Choi S, Beer J, Bourgeois J, et al. Pityriasis alba in pediatric patients with skin of color. J Drugs Dermatol. 2023;22(4):417-418. doi:10.36849/JDD.7221.
Background:
Pityriasis alba is a common skin condition that may be challenging to treat, especially in patients with darker skin type where the hypopigmentation may be more noticeable and represents a major cosmetic concern.
Objectives:
This study aims to evaluate the efficacy of three cost-effective treatments of PA in comparison with placebo.
Patients/methods:
This prospective study was conducted on 80 patients complaining from PA and divided into 4 equal groups according the received topical treatment on the target lesions twice daily for 8 weeks (Calcipotriol 0.005% cream, Tacrolimus 0.03% ointment, topical corticosteroid; Clobetasone butyrate 0.05% cream and Petrolatum as Placebo). Clinical evaluation, Physician Global Assessment, Patient's satisfaction levels as well as point counting planimetry were done for evaluation of the response.
Results:
Significant improvement of scaling and erythema within 3 weeks after initiation of therapy and hypopigmentation by the 8th week, except for those received placebo. Tarolimus 0.03% ointment showed simple superiority over both Calcipotriol 0.005% cream and topical corticosteroid as regards repigmenation, although, the later received the highest level of patient satisfaction.
Conclusion:
The three treatments were superior to placebo with relative superiority to Tarolimus 0.03% due to limited side effects.
Pigmentary disorders, both hypo and hyper, are common in pigmented skin. More common hypopigmentary disorders, such as leprosy, vitiligo and photodermatoses are discussed in separate chapters. Pityriasis alba, progressive macular hypomelanosis and idiopathic guttate hypomelanosis are easily visible, and common cosmetic problems in pigmented skin, and by no means a concern in White skin. Customer can order it via https://www.springer.com/in/book/9789811554827.
There are several dermatoses that are thought to be related to atopic dermatitis. These include pityriasis alba, seborrhoeic dermatitis, nummular eczema, pompholyx and prurigo. Pityriasis alba is characterized by hypopigmented patches that are covered with fine scales mainly localized on the face. It could be considered as a minor criterion for diagnosis of atopic dermatitis. Pompholyx usually appears as deep‐seated vesicles or bullae, located mainly or commonly on the edges of the fingers, toes, palms and soles. It may be followed by scaling and lichenification of the skin. Nummular eczema is characterized by formation of pruritic discoid plaques commonly affecting the extensor surfaces of the limbs. Another type of dermatitis is seborrhoeic dermatitis that presents in areas of the skin that are rich in sebaceous glands. Lesions are erythematous, scaly plaques or take the form of cradle cap. Lichen simplex chronicus and prurigo are highly pruritic lesions that occur as a result of excessive itching of the skin. Corticosteroids in addition to calcineurin inhibitors are the main treatment.
Hypopigmentation of the skin is frequently encountered in childhood. Such a presentation can be either congenital or acquired, and generalized or more localized. Considering that hypopigmentation can be an early indication of serious (congenital) conditions, a medical history and thorough clinical examination, including Wood's light investigation, is important. In this chapter, the clinical diagnosis, aetiology and management of different types of congenital and acquired hypopigmentary disorders will be discussed.
White diseases are a heterogenous group characterized by hypo- or depigmentation. Skin and eye color are determined by the number and size of melanosomes present. Melanin is produced by melanosomes in the melanocytes present within the epidermis of the skin, uvea, and retinal pigmented epithelium (RPE). Conditions altering the number of melanocytes or concentration of melanin result in a lack of pigmentation, appearing as “white diseases” ranging from the well-known albinism and vitiligo to more esoteric white hand syndrome and Degos' disease.
Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphological findings, can aid in delineating the causes of acquired hypopigmented disorders. Part II of this two-part series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.
Pityriasis alba is een onschuldige huidaandoening die vooral bij kinderen en adolescenten voorkomt en gekenmerkt wordt door matig tot scherp begrensde, gehypopigmenteerde huidafwijkingen. Deze zijn meestal gelokaliseerd in het gelaat en vallen vooral op bij mensen met een donkere huid.
The study of pediatric skin of color encompasses a variety of beautiful birthmarks, reactive pigmentary changes, and altered disease morphologies and prevalences compared to patients with fair skin. This chapter discusses noteworthy congenital and acquired conditions in children with darker skin, including their psychosocial impact.
The introduction of glucocorticosteroids in dermatology was the greatest progress for eczema patients in the second half of the twentieth century. For atopic dermatitis, mostly mild to moderate strength steroids are adequate. The application of topical glucocorticosteroids in the correct vehicle should be timely limited and ended via a “tandem therapy.” Proactive strategies with once or twice weekly applications of the effective substance have proven helpful. The most important side effects of topical glucocorticosteroids include skin atrophy and the common manifestation of perioral rosacea-like dermatitis which occurs especially in young women after topical corticosteroids.
Eczematous eruptions are very common in children. Atopic dermatitis affects 10–20 % of children in several industrialized countries and is increasing in prevalence in many parts of the world. This chapter outlines the evaluation and evidenced-based treatment of atopic dermatitis as well as other common eczematous conditions including: pityriasis alba, contact dermatitis, juvenile plantar dermatosis, nummular dermatitis, lichen striatus, lichen simplex chronicus, and seborrheic dermatitis.
Children of color include a broad variety of ethnic types, skin tones, and genetic backgrounds. Broadly, the grouping includes Black, Hispanic, Asian, Indian, and Middle Eastern children. The United States is referred to as a melting pot, and, indeed, children with genetic backgrounds from the far reaches of the world can be seen in North America due to immigration patterns. These global immigration patterns have helped to introduce both new patterns of disease and new cutaneous infectious diseases into the North American pediatric population. This chapter provides an overview of pediatric dermatologic diseases as they pertain to skin of color. The first section looks at the development of skin and soft tissue structures in children of color, the second examines the presentation of common childhood diseases in children of color, and the third looks specifically at diseases genetically limited to children of color.
A 15-year-old Fitzpatrick Skin Type (FST) IV female with a history of atopic dermatitis and allergic rhinitis presented with light spots on her bilateral cheeks since childhood, worse in the summer, with occasional associated pruritus.
East Asians have a large range of skin types and different cultural beliefs.Knowledge about normal variations in skin color and common pigmentary disorders among East Asians is essential to avoid overdiagnosis.Although most pigmentation disorders are benign or non specific, some pigmentation disorders present cosmetic or psychological challenges to the patient, necessitating systematic evaluation and treatment.Pigmentary disorders are broadly classified into three groups:1.
Hypopigmentation or depigmentation
2.
Hyperpigmentation
3.
Mixed
These disorders can be further subcategorized based on their age of onset, pattern and distribution. i.e., Hypomelanosis of lto is categorized under early onset patterned hypopigmentary disorder.
Atopic dermatitis (AD) represents a chronic inflammatory skin disease which is mostly associated with severe pruritus. For the treatment of AD the stage of the disease and complications such as bacterial superinfection of AD have to be considered. There are a number of external and internal treatment options for AD available. Over a long period a change of the individual treatment strategy might be indicated. For external treatment of AD symptoms not only emollients, but also anti-inflammatory and antipruritic substances might be necessary. The efficacy of topical steroids for the treatment of AD has sufficiently been demonstrated in a series of clinical trials. To reduce the risk for side effects the potency, the frequency and duration of usage as well as the localization of application and the patients age should be considered. Topical calcineurin inhibitors represent a further anti-inflammatory treatment option. Regarding the recommendation of the EMEA (European Medicines Agency) topical calcineurin inhibitors should be prescribed as "second-line" therapy in case of a risk for irreversible side effects or in case use of topical steroids is not possible. Since "ultra-long" experiences remain to be assessed, topical calcineurin inhibitors should be prescribed up from the age of 3, and tacrolimus 0.1% from the age of 17, respectively. Atopi-cal antiseptic treatment is indicated in cases of clinical manifestation of superinfection of AD. In order to reduce the risk for the development of bacterial resistance and epicutaneous sensitization topical antibiotics should temporarily be applied. UV-irradiation represents a further therapeutic option which can also be combined with topical steroids.
Follicular disorders are possibly a commonly seen group of disorder which are defined as being localized around follicles and appendages and clinically present as small papules .Classically clinicopathological follicular plugging should be demonstrated in the “true” follicular disorders which are appropriately referred to as follicular keratosis. Another subtype is folliculitis (infectious or non infectious) and the follicular mimickers which clinically resemble “true” follicular disorders without the follicular keratoses . Acne vulgaris has a amalgamation of all the above lesion types .
The “true” follicular disorders can have two clinical presentations , either keratotic papules or papules with prominent spines . The common disorders seen on the face include keratosis rubra pilaris, erythromelanosis follicularis , Dariers disease , pityriasis rubra pilaris, phrynoderma, follicular dermatitis, and lichen spinulosus .Rare disorder can be sometimes crucial markers for underlying disorder and include AIDS associated follicular eruptions , trichodysplasia spinulosa,MMDK,hyeprkeratotic spicules and acquired perforating disorders . The evergreen mimickers sarcoidosis ,syphilis ,drug eruptions, and contact dermatitis true to their reputation also have follicular presentations
The 2nd Annual Current Trends in Pediatric Dermatology Series was held in New York City (NY, USA) on November 8, 2009. With an attendance of over 150 people, this event brought together prominent guest speakers from multiple disciplines, including pediatrics, dermatology and endocrinology. This continuing medical education series addressed a number of common clinical scenarios within the realm of pediatric dermatology, and also reviewed current and newly developed therapeutic options. This lecture series contained many clinical pearls, useful for both full practicing physicians, as well as residents. This review contains an overview of some of the salient issues discussed at the meeting.
The 17th Congress of the European Academy of Dermatology and Venereology took place in Paris on 17–20 September 2008 and brought together nearly 11 000 participants. Various plenary lectures, subspecialty meetings, ‘free communications’, ‘top ten’, ‘test yourself’ and ‘junior’ sessions, 19 courses and 14 ‘lunches with the expert’, six forums, 27 symposia and 45 workshops were pressed into the 4 days of the meeting. Over 1700 posters were presented and exhibited. The themes of a number of symposiums, workshops and sessions overlapped, offering additional educational opportunities despite a very busy schedule. The meeting was well organized. Aesthetic dermatology comprised a significant part of the meeting. It is impossible to encompass all important presentations and we highlight a few medical pearls presented at the meeting; however, our report is not intended as a substitute for reading the conference proceedings and related references quoted in this article.
Objective:
Pityriasis alba (PA) is the most common cause of facial hypopigmentation presenting to the dermatologist. The objective of the current study was to study the effect of the 308-nm excimer laser in the treatment of PA.
Materials and methods:
Twelve patients with 37 PA patches were enrolled in this study. The lesions were treated using the 308-nm excimer laser twice a week for 12 weeks. The hypopigmented areas were evaluated at baseline and at weeks 0, 3, 6, and 12 for scaling, hypopigmentation, and pruritus on a 4-point scale (0 = none to 3 = severe). All adverse effects were recorded.
Results:
There were seven male and five female participants in (aged 5-21 years), with skin type III to V. After 1 month of laser therapy, the clinical scores were significantly lower than at baseline. Similar decreases were observed for the scaling and pruritus scores. Uneven skin color improved by the third week, and near-complete resolution was noticed by the end of 3 months. No serious or unpleasant side-effects were observed, and all patients completed the 12-week treatment. Patients were satisfied or very satisfied with the treatment.
Conclusion:
The 308-nm excimer laser is an effective therapeutic option for PA.
Dark-skinned patients manifest the signs of skin aging differently than their fair-skinned counterparts in that the former exhibit more intrinsic facial aging, whereas the later shows more photodamage. Nevertheless, common cosmetic procedures can be used in skin of color to treat the signs of aging.
To provide updated clinical information on the use of cosmetic procedures for skin aging in darker phototypes for the safe treatment of this population.
A Medline literature search was performed for publications on the safety and efficacy of botulinum toxin, dermal fillers, chemical peels, laser and light-based devices, and microdermabrasion for the treatment of skin aging specifically in ethnic populations.
Similarly to light-skinned patients, botulinum toxin and dermal fillers provide fast, effective results in skin of color, with fewer complications than with traditional surgery and no downtime. More-invasive procedures, such as chemical peeling, laser resurfacing, and microdermabrasion, can also be effective, but it is important to exercise caution and remain within certain parameters given the greater risk of dyschromias in this population.
With the proper knowledge of how to treat aging skin of color, these patients can experience the benefits of cosmetic procedures while minimizing the risks.
Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.
Tacrolimus is an ascomycin macrolactam derivative with immunomodulatory and anti-inflammatory activity that belongs to the class of calcineurin inhibitors. Tacrolimus in its topical formulation has been established as a safe and effective alternative to topical corticosteroids because of its mild side effects and its minimal systemic absorption. Topical tacrolimus has been approved for the treatment of atopic dermatitis in two concentrations, 0.03 and 0.1%. In a thorough research of literature the authors review all of the available data regarding the off-label uses of the medication in other dermatoses. It seems that compared to pimecrolimus, tacrolimus has proved to be a more effective treatment. There is no causal relationship that has been established between tacrolimus and carcinogenesis. Furthermore, the authors believe that, without any evidence, the theoretical concerns are not enough to produce warnings. Tacrolimus ointment 0.1% may be recommended as a first-line choice for seborrheic dermatitis of the face and trunk, facial and intertriginous psoriasis and probably for allergic contact dermatitis and Zoon's balanitis. It has been ineffective in numerous dermatoses such as alopecia areata, necrobiosis lipoidica, internal pruritus and in thick hyperkeratotic plaques of psoriasis when administered as the commercially available formulation without occlusion. There is yet unexploited therapeutic potential regarding the use of topical tacrolimus in dermatology. Isolated cases of successful administration of the medication in various cutaneous conditions require further large-scale studies to clarify the actual effectiveness.
Loss of pigment, either partial (hypopigmentation) or complete (depigmentation), can have a profound psychological impact, perhaps seemingly out of proportion for something that is almost exclusively benign.(1) Remarkably, hypopigmentation has been referenced in many ancient religious texts, often in the context of being a curse or contagious disease, firmly securing this cutaneous malady at the very deepest level of culture.(2) A compelling illustration of this occurs in the Old Testament when Miriam speaks against Moses and is punished thusly: "... suddenly Miriam became leprous, as white as snow."(3) It is difficult to imagine a more wicked association for a skin disease than such an execration. Although the vast majority of hypopigmentation encountered in the modern world is neither contagious nor dangerous, fear, anxiety and uncertainty continue to surround this problem for patient and physician alike. An exhaustive list of causes of hypopigmentation and depigmentation would contain many rare and obscure entities, but in this review the focus will be limited to three of the most common causes of acquired loss of pigment in children.(4) By closely examining pityriasis alba, pityriasis (tinea) versicolor, and vitiligo, some of the fear, anxiety and uncertainty may be dispelled and, even if they cannot be cured, simple understanding may provide some relief.
FK506, a neutral macrolide with immunosuppressive properties, was shown to selectively and rapidly inhibit the accumulation of IL-2 mRNA, as well as the mRNAs of other early (E) phase T cell activation genes such as IL-3, IL-4, GM-CSF, TNF alpha, IFN-gamma, and c-myc in activated human peripheral blood T cells. The activity of FK506, when compared to Cyclosporin A, another immunosuppressant, was 10 to 100x more potent in its ability to inhibit IL-2 mRNA synthesis. FK506 inhibited IL-2 mRNA accumulation in Con A, Con A plus PMA, Ionomycin plus PMA, anti-CD3, and anti-CD3 plus PMA activated T cells. Transcripts from other T cell gene classes such as the immediate early (IE) phase gene, c-fos, the late phase (L) genes, transferrin receptor, IL-2R alpha-chain, and TNF-beta, and the constitutive class genes glyceraldehyde-3-phosphate dehydrogenase and class I MHC HLA-B7 were not affected by FK506. The macrolide Rapamycin, which is structurally related to FK506, had no inhibitory effect on IE, E, L, or constitutive class mRNAs, but it appeared to increase the levels of the E-phase transcripts that were inhibited in FK506 treated T cells. The effect of FK506 on inducible genes in non-T and non-lymphoid human cells was studied in LPS-induced monocytes and PMA or IL-1 activated synovial fibroblasts. FK506 did not affect expression of the mRNAs for IL-1 alpha or IL-1 beta in human monocytes, or of stromelysin, collagenase, or TIMP in synovial fibroblasts. Nuclear run-off transcription studies indicate that FK506 inhibits transcription of the IL-2 gene. These studies suggest that Cyclosporin A and FK506 may effect a common early event in the T cell activation pathway.
Tacrolimus ointment (Protopic®) is a topically applied macrolide lactone immunomodulator effective in the treatment of atopic dermatitis. Its mechanism of action primarily involves calcineurin inhibition, which interrupts cytokine gene expression and leads to the downregulation of T-cell activity.
Tacrolimus ointment (0.03% and 0.1% for adults and 0.03% for children) is an effective treatment for atopic dermatitis of the trunk and limbs, as well as sensitive skin areas such as the face. Its efficacy is similar to or greater than that of hydrocortisone acetate 1%, hydrocortisone butyrate 0.1% and betamethsone valerate 0.12% ointments and pimecrolimus 1% cream. Systemic absorption of tacrolimus from the ointment is minimal, and adverse events, which are mostly associated with the application site and include skin burning and pruritus, tend to resolve early in treatment. Unlike topical corticosteroids, tacrolimus ointment is not associated with skin atrophy, and it is a well tolerated treatment for adults or children with atopic dermatitis, particularly when long-term treatment is indicated or the face or skin-fold regions are involved.
Pharmacological Properties
Tacrolimus ointment has demonstrated immunomodulatory and anti-inflammatory properties in animal models and human studies. The primary mechanism of action of tacrolimus in the treatment of atopic dermatitis involves calcineurin inhibition, which leads to downregulation of antigen-specific T-cell reactivity and interruption of the transcription of genes for a range of proinflammatory cytokines important in the pathophysiology of the early immune response. Additional mechanisms of action may include actions on other cells (dendritic cells, mast cells, keratinocytes, basophils and eosinophils) important in the pathophysiology of atopic dermatitis.
Unlike topical corticosteroids, tacrolimus 0.1% or 0.3% ointment does not interfere with collagen synthesis or induce skin atrophy (0.3% ointment is not available commercially).
Systemic absorption of tacrolimus from the 0.03% or 0.1% ointment in adults and children with atopic dermatitis was minimal; systemic exposure following topical application of tacrolimus 0.1% ointment to atopic dermatitis lesions was approximately 1.5% (in adults) and 3% (in children) of that following oral administration of the drug (dose not specified) [body surface area treated was up to 10 000 cm2 in adults and up to 5000 cm2 in children]. Blood concentrations during studies were generally
Pityriasis alba was first described by Fox in 1923, 1924, and 1925.1-3 He was unable to account for its pathogenesis, and it remained unnamed for many years. Discussions of the condition have appeared subsequently in the literature, and descriptive titles have been numerous. The current appelation, that used by O'Farrel4 and by Wells et al.5 in their recent review of this subject, is suitable from a morphological standpoint.Pityriasis alba is characterized by superficial, lightly scaling areas of depigmentation, circinate or ovate in shape in most instances, although some may have irregular borders. The borders are quite distinct, particularly if the achromia occurs in deeply pigmented skin. They vary in size from 0.5 to 6 cm. in diameter, and in color from ivory to light pink. Most authors agree that the face is the site of predilection, but involvement of other areas of the body is often
Atopic dermatitis (AD) is a common, chronically recurring skin disorder. Dry skin is a common finding in patients with AD, apart from the dermatitis. Although there are obvious clinical signs of an impaired barrier function of the skin, few investigators have studied this aspect of AD. The stratum corneum, where the barrier is located, has been studied with different techniques in patients with AD, and the results are now presented. The water-binding capacity of dry atopic skin was found to be reduced when measured with an in vitro microbalance technique. TEWL (transepidermal water loss) measured with and Evaporimeter Ep1, was increased in dry skin and in clinically normal skin of atopics on predilection areas. Water content was decreased in dry atopic skin, when measured with the Corneometer CM 420. In a quantitative electron microscopic study, the lamellar bodies were found to have an increased relative volume in dry atopic skin. When using chromatographic analysis, preliminary data suggested reduced amounts of extractable stratum corneum lipids in patients with AD. In a clinical study, 80% of the patients with AD regarded their skin as being dry. Fifty percent were found to have areas of dry skin, on clinical examination. By scanning electron microscopy (SEM), the surface pattern of dry atopic skin was found to be coarse and irregular. When using profilometry, quantitative differences in roughness parameters were found in dry atopic vis-à-vis to normal skin.(ABSTRACT TRUNCATED AT 250 WORDS)
FK506, a neutral macrolide with immunosuppressive properties, was shown to selectively and rapidly inhibit the accumulation of IL-2 mRNA, as well as the mRNAs of other early (E) phase T cell activation genes such as IL-3, IL-4, GM-CSF, TNF alpha, IFN-gamma, and c-myc in activated human peripheral blood T cells. The activity of FK506, when compared to Cyclosporin A, another immunosuppressant, was 10 to 100x more potent in its ability to inhibit IL-2 mRNA synthesis. FK506 inhibited IL-2 mRNA accumulation in Con A, Con A plus PMA, Ionomycin plus PMA, anti-CD3, and anti-CD3 plus PMA activated T cells. Transcripts from other T cell gene classes such as the immediate early (IE) phase gene, c-fos, the late phase (L) genes, transferrin receptor, IL-2R alpha-chain, and TNF-beta, and the constitutive class genes glyceraldehyde-3-phosphate dehydrogenase and class I MHC HLA-B7 were not affected by FK506. The macrolide Rapamycin, which is structurally related to FK506, had no inhibitory effect on IE, E, L, or constitutive class mRNAs, but it appeared to increase the levels of the E-phase transcripts that were inhibited in FK506 treated T cells. The effect of FK506 on inducible genes in non-T and non-lymphoid human cells was studied in LPS-induced monocytes and PMA or IL-1 activated synovial fibroblasts. FK506 did not affect expression of the mRNAs for IL-1 alpha or IL-1 beta in human monocytes, or of stromelysin, collagenase, or TIMP in synovial fibroblasts. Nuclear run-off transcription studies indicate that FK506 inhibits transcription of the IL-2 gene. These studies suggest that Cyclosporin A and FK506 may effect a common early event in the T cell activation pathway.
Pityriasis Alba, a dermatosis whose significance is basically cosmetic, is extremely common and so benign that the majority of patients-dark skinned children and young people do not consult a physician. Nevertheless due to its high incidence and chronicity a large number of patients eventually seek relief. The various treatments currently employed based on a mistaken concept of its etiology are ineffective, though the dermatosis disappears spontaneously after some time. The use of cream containing 2% coal tar., 1% diiodohydroxyquinolin and 0.5% hydrocortisone applied 3 times a day for one month on 29 patients in a double blind trial compared with on the contralateral region, proved to have acceptable results, with a highly significant difference compared with the placebo (P less than 0,0005).
The aetiology of pityriasis alba (PA), a common dermatosis in childhood, is still controversial. The objective of this study was to assess the possible aetiopathogenic factors of this disease in infants.
Forty-four patients with PA and 31 healthy children were examined and compared. Personal hygiene habits, sun exposure, presence of Staphylococcus aureus in nasal fossae and presence of major or minor signs of atopy were assessed during anamnesis and physical examination. Susceptibility to ultraviolet (UV) B radiation was measured by the onset of a contact hypersensitivity reaction to diphenylcyclopropenone in individuals sensitized in previously irradiated areas.
The prevalence of PA was higher in individuals with darker skin, in high phototype categories, as well as in males. The number of daily baths and sun exposure between 10.00 h and 15.00 h were significantly higher in the PA group when compared with controls (P = 0.03 and P = 0.0015, respectively). The presence of atopy signs was more common in pityriasis patients (P = 0.002). Susceptibility to UVB radiation was 29.6% in the PA group vs. 29.0% in the control group; nevertheless, important differences were found after stratification in order to control possible confounding factors. The presence of S. aureus in the nostrils was equal in both groups.
Our results confirm that PA, in our population, is more prevalent in males and in individuals in higher phototype categories. In those with inadequate personal hygiene and sun exposure habits the disease is more accentuated, demonstrating that the xerosis presenting in individuals with atopic diathesis is an important element in the development of the disease. S. aureus is not an important aetiopathogenic factor in PA. Susceptibility to UVB becomes important when related to the patient's phototype.
Tacrolimus ointment (Protopic) is a topically applied macrolide lactone immunomodulator effective in the treatment of atopic dermatitis. Its mechanism of action primarily involves calcineurin inhibition, which interrupts cytokine gene expression and leads to the downregulation of T-cell activity. Tacrolimus ointment (0.03% and 0.1% for adults and 0.03% for children) is an effective treatment for atopic dermatitis of the trunk and limbs, as well as sensitive skin areas such as the face. Its efficacy is similar to or greater than that of hydrocortisone acetate 1%, hydrocortisone butyrate 0.1% and betamethsone valerate 0.12% ointments and pimecrolimus 1% cream. Systemic absorption of tacrolimus from the ointment is minimal, and adverse events, which are mostly associated with the application site and include skin burning and pruritus, tend to resolve early in treatment. Unlike topical corticosteroids, tacrolimus ointment is not associated with skin atrophy, and it is a well tolerated treatment for adults or children with atopic dermatitis, particularly when long-term treatment is indicated or the face or skin-fold regions are involved.
Atopic dermatis (AD) is a chronic disease that often requires long-term treatment. Topical corticosteroids are the usual therapy for patients with AD, but prolonged usage can result in skin atrophy and other side-effects.
In a randomized, double-blind, comparative study, to compare the efficacy and safety of a 6-month treatment period with 0.1% tacrolimus ointment vs. a corticosteroid ointment regimen in adults with moderate to severe AD.
Treatment was applied twice daily for a maximum of 6 months. Patients in the tacrolimus treatment group (n = 487) applied 0.1% tacrolimus ointment to all affected areas over the whole body. The patients treated with the corticosteroid regimen (n = 485) applied 0.1% hydrocortisone butyrate ointment to affected areas on the trunk and extremities and 1% hydrocortisone acetate ointment to affected areas on the face and neck. The study primary endpoint was the response rate, i.e. the proportion of patients with at least 60% improvement in the modified Eczema Area and Severity Index (mEASI) between baseline and month 3.
By month 3, more patients in the 0.1% tacrolimus group responded to treatment (72.6% vs. 52.3% in the corticosteroid group, P < 0.001). The patients treated with 0.1% tacrolimus also showed greater improvement in mEASI, EASI, affected body surface area and physician and patient assessments of global response. Patients applying 0.1% tacrolimus ointment experienced more skin burning (52.4% vs. 13.8% in the corticosteroid group; P < 0.001). In most patients, skin burning was mild to moderate in severity and decreased rapidly after the first week of treatment. There was no increase in the incidence of infections or malignancies over time in either treatment group.
Long-term treatment with 0.1% tacrolimus ointment is significantly more efficacious than a corticosteroid ointment regimen in adults with moderate to severe AD.