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Dermatology Update


The Mechanisms and Consequences of Ultraviolet-Induced Immunosuppressant in the Skin and Eye

Ultraviolet radiation (UVR) of the skin results in immune suppression to antigens encountered shortly after the exposure. The pathways leading to the downregulation in immunity are complex, initiated by chromophores located at the surface of the skin and ending with the generation of immunosuppressive mediators and regulatory cells.

Ultraviolet-induced immunosuppression can be considered not only as beneficial, such as in preventing chronic inflammatory responses and allergic and automimmune reactions, but it can also be detrimental, such as in the lack of control of skin tumors and infectious diseases. The eye is an immune privileged site through a wide variety of mechanisms that allow selected immune responses without causing inflammation. The role of UVR in altering immune responses in the eye is not clear and is discussed in relation to photokeratitis, herpetic stromal keratitis, and pterygium. 

Eye & Contact Lens: Science & Clinical Practice:   July 2011

Black tattoo inks are a source of problematic substances such as dibutyl phthalate



Tattooing has recently become increasingly popular. Using tiny needles, tattooists place the tattoo ink in the dermis along with numerous unknown ingredients. Most tattoos consist of black inks, which are predominantly composed of soot products (carbon black with polycyclic aromatic hydrocarbons).


Black tattoos cause skin problems, including allergic reactions, but the responsible substance frequently remains unknown.


We applied gas chromatograph–mass spectrometry analysis to search for hazardous compounds in 14 different commercially available black tattoo ink samples.


The analysis revealed that all inks contained the softener substance dibutyl phthalate (0.12–691.2 µg/g). Some of the inks contained hexachloro-1,3-butadiene (0.08–4.52 µg/g), metheneamine (0.08–21.64 µg/g), dibenzofuran (0.02–1.62 µg/g), benzophenone (0.26–556.66 µg/g), and 9-fluorenone (0.04–3.04 µg/g).


The sensitizing agent dibutyl phthalate acts directly on keratinocytes and can drive Th2 responses following skin exposure via induction of thymic stromal lymphopoietin gene expression. Hexachloro-1,3-butadiene is genotoxic in vitroand 9-fluorenone is cytotoxic, generating reactive oxygen species under light exposure. The substances found in the inks might be partially responsible for adverse skin reactions to tattoos.

Contact Dermatitis  Article first published online: 3 JUL 2011

Sunlight exposure-mediated DNA damage in young adults


Previous experimental studies showed that single ultraviolet B light (UVB) irradiation increased levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG), a well-established biomarker of carcinogenesis as well as oxidative DNA damage, in epithelial cells in animals and humans. We performed for the first time an epidemiological study to investigate the correlations among levels of oxidative DNA damage, skin pigmentation and sunlight exposure in human daily life.


Digitalized skin pigmentation levels and creatinine-adjusted urinary 8-OHdG levels were examined in 127 healthy young adults aged from 20 to 24 years and in hairless mice with normal pigmented skin (HL-mice; n=20) and hyperpigmented skin (HL-HPS-mice; n=20). Data obtained by a questionnaire were also analyzed for the 127 subjects.


Binary logistic regression analysis showed that increased sunlight intensity, but not sunlight-exposed time or sunlight-exposed skin area, was correlated with elevation of creatinine-adjusted urinary 8-OHdG levels. In contrast, increased skin pigmentation level, but not use of sunscreen, was correlated with reduction of urinary 8-OHdG level in humans. UVB irradiation corresponding to several minutes of sunlight exposure significantly increased urinary 8-OHdG levels in HL-mice but not in HL-HPS-mice.


We demonstrated that increase in intensity of sunlight in human daily life increased levels of DNA damage. We also demonstrated a protective effect of skin pigmentation on sunlight exposure-mediated DNA damage. Impact: We have provided more reliable evidence of routine sunlight exposure-mediated DNA damage in humans through the combination of epidemiological and experimental studies.

Cancer Epidemiology, Biomarkers &  Prevention .2011 Jun 15. [Epub ahead of print]

(A publication of The American Association for Cancer Research)

Approach to reticulate hyperpigmentation                

Reticulate hyperpigmentation is a feature of a number of conditions, which differ in age of onset and distribution of the lesions. Associated clinical findings (e.g. hair, nail, teeth, systemic involvement), are used to differentiate between the conditions. Histopathological examination is useful in some disorders.

Diagnosing the disorders is important, because the underlying causes may be treatable, and some of the disorders are associated with malignancies and life-threatening systemic involvement. In this review, I present a concise, systematic approach to the treatment of the patient with reticulate hyperpigmentation.

                                    Clinical and Experimental Dermatology  July 2011


Periorbital Hyperpigmentation in Asians: An Epidemiologic Study and a Proposed Classification               

BACKGROUND Periorbital hyperpigmentation (POH) presents with a dark area surrounding the eyelids. It is an ill-defined condition, and the pathogenesis can be multifactorial.

OBJECTIVE This epidemiologic study was conducted to assess the prevalence of periorbital hyperpigmentation in Singapore in an attempt to propose a classification.

MATERIALS AND METHODS One thousand consecutive patients attending the general dermatology clinic at the National Skin Center were enrolled in the study to assess for POH, of whom 200 with POH were examined and investigated to define the cause of POH. The possible causes were determined according to a detailed history, clinical examination, and assessment by three dermatologists. The extent of the POH was measured using a mexameter.

RESULTS The commonest form of POH was the vascular type (41.8%), followed by constitutional (38.6%), postinflammatory hyperpigmentation (12%), and shadow effects (11.4%). The vascular type was seen predominantly in Chinese, whereas as the constitutional type was most common in Indians and Malays.

CONCLUSION The vascular form of POH was the predominant type. We propose a comprehensive classification for POH that we hope will influence the choice of treatment modalities used in managing POH in the future.

Dermatologic Surgery  published online: 17 JUN 2011


Preventing melasma recurrence: prescribing a maintenance regimen with an effective triple combination cream based on long-standing clinical severity.


The relapsing nature of melasma emphasizes the need to maintain efficacy achieved after acute treatment.


To compare clinical efficacy and safety of two 6-month Triple Combination (TC; containing fluocinolone acetonide, hydroquinone and tretinoin) maintenance regimens in subjects with moderate to severe melasma, after daily treatment up to 8 weeks.


This randomized, investigator-blinded, controlled study had a maintenance phase of 6 months. Sixteen centres in Brazil and Mexico enrolled 242 subjects 18 years or older attaining no or mild melasma after 8 weeks of daily TC applications. Subjects were randomized to receive TC in a twice weekly or tapering regimen [3/week (1st month), 2/week (2nd month), 1/week (4th month)]. Efficacy and safety measurements included median time to relapse and relapse-free rate, Global Severity Score, Melasma Area and Severity Index score (MASI), subject's assessment, quality of life questionnaire (MelasQol), and adverse events.


The majority (78.8%) had no or mild melasma (GSS ≤ 1) at week 8 and entered maintenance phase. After 6 months, 53% of patients remained relapse-free with improved quality of life, and time to relapse was similar between groups (about 190 days). Melasma severity at study entry, not maintenance baseline, influenced relapse rate. The twice weekly regimen tended to show better effectiveness in postponing relapse in severe melasma. Both regimens were safe.

Conclusion. After resolution of melasma with TC, maintenance therapy over 6 months was successful in preventing relapse in over half of the patients who entered maintenance phase. Prescribing medicines should be adapted to patients based on melasma severity.

Journal of European Academy of Dermatology &  Venereology  2011 May 31. [Epub ahead of print]


Further enhancement of facial appearance with a hydroquinone skin care system plus tretinoin in patients previously treated with botulinum toxin type a.


A hydroquinone (HQ) skin care system has been designed for use in conjunction with nonsurgical procedures.


 The authors evaluate the efficacy of this system plus tretinoin for improving facial appearance in comparison to a standard skin care regimen in users of botulinum toxin Type A (BoNT-A).


 In this multicenter, randomized, investigator-masked, parallel-group study, 61 patients who received upper facial treatment with BoNT-A at a plastic surgery or dermatology clinic were randomly assigned to apply either the HQ system (cleanser, toner, proprietary 4% hydroquinone, exfoliant, and sunscreen) plus 0.05% tretinoin cream or a standard skin care regimen (cleanser, moisturizer, and sunscreen) for 120 days. Outcomes were assessed by the investigators and through a patient questionnaire.


Compared with standard skin care, the HQ system plus tretinoin resulted in significantly milder fine lines/wrinkles and hyperpigmentation at Days 30, 90, and 120 (p ≤ .05) and significantly superior overall ratings for each of nine patient assessments at Days 90 and 120 (p ≤ .05).

A relatively greater proportion of patients using the HQ system plus tretinoin believed that their study treatment had further enhanced the improvements attained with BoNT-A (86% vs 8%). Both regimens were generally well tolerated.


Adjunctive use of the HQ system plus tretinoin can further enhance the improvements in facial appearance attained with BoNT-A. Applying the HQ system plus tretinoin offers multiple clinical benefits over standard skin care, including significantly greater improvements in fine lines/wrinkles and hyperpigmentation

 Aesthet Surg J.2011 Jul 1;31(5):529-39.

Woman Receives Full Face Transplant After Being Mauled By A Chimpanzee

Charla Nash, 57, whose face was mauled by a furious 200-pound pet chimpanzee in February 2009, has undergone a full face transplant at Brigham and Women's Hospital, Dr. Bohdan Pomahac, medical team leader announced. The animal attack left her blind. Nash says she yearns to be able to eat pizza and hamburgers again; quite a change from the pureed foods she has had to live on over the last few months.

The chimpanzee's owner had asked Nash help her coax the animal back into the house. Her hands were ripped off, as were her nose, lips and eyelids. The police intervened and shot the chimp dead, but not soon enough to prevent her dreadful injuries.

This is the third full face transplant in the United States. A team of 30 medical professionals were involved in replacing nerves, blood vessels, underlying muscles, her teeth and hard palate.

Dr. Pomahac said that overall, her prognosis looks good. Nash also underwent a double hand transplant in May. Unfortunately, she had a pneumonia complication, resulting in a serious drop in blood pressure, this undermined the blood supply to her hands, and they eventually had to be removed. However, Pomahac said she might still be a candidate for another hand transplant.

Dr. Pohamac said:

"She will eventually be able to eat a hamburger, something she said was very important her, having only had pureed food since her injury, and I think we can all relate to that."

Medical Newstoday   11th June 2011

Prospective Study of UV Exposure and Cancer Incidence Among Swedish Women

Background:Except for skin melanoma and nonmelanoma skin cancer, little evidence from prospective studies is available on the association between UV exposure and cancer risk.

Methods:We followed prospectively 49,261 women aged 30 to 49 years at enrollment in 1991 to 1992 for 15 years. Cancer incidence was analyzed by fitting Cox models, and estimating hazard ratios (HR) and 95% confidence intervals (CI).

Results:2,303 incident cases of cancer were diagnosed (breast: 1,053, ovary: 126, lung: 116, colon-rectum: 133, and brain: 116). No associations were found between any cumulative measure of UV exposure at ages 10 to 39 years and overall cancer risk. However, spending ≥1 week/year between ages 10 and 29 years on sunbathing vacations led to an inverse association with overall cancer risk (HR: 0.70, 95% CI: 0.53–0.93) and breast cancer risk (HR: 0.56, 95% CI: 0.36–0.89) when compared with women who never went on such vacations. Solarium use was inversely associated with breast cancer risk, whereas ≥2 sunburns/year was inversely associated with lung cancer risk. No other associations were found between sun exposure or solarium use at ages 10 to 39 years and cancer risk.

Conclusion:We found no evidence of an association between any cumulative measure of UV exposure at ages 10 to 39 years and overall cancer risk. UV exposure earlier in life was related to reduced overall and breast cancer risk.

Impact:Further research is needed to define the amount of solar or artificial UV exposure that may, or may not, be beneficial for cancer prevention.

Cancer Epidemiology, Biomarkers & Prevention: 20(7): 1-10, @2011 AACR

                                           . . .  dangerous, some are even life threatening

There are, of course, many skin conditions out there. Some of them are innocuous. They may be annoying and/or uncomfortable, but they are typically easily treatable. However, there are a number of conditions out there so serious that they are dangerous, even life threatening.

Pemphigus Vulgaris

This is one of many skin disorders which comes in the form of a rash. It tends to occur in adults over the age of forty but can occur in children as well. Also known as PV, it manifests with irregularly shaped blisters and lesions which begin forming in the mouth. If not properly treated, these blisters can break open, which allows them to become seriously infected. These infections can actually end in death.

Lichen Planus

This is a disorder which can affect the mucus membranes in your body and your skin. Typically, it comes with a raised, shiny, and itchy rash. The bumps vary between purple and pink in color, but they tend to be quite small. Scaly patches of skin are not uncommon either. The rash may extend to the inside of your mouth, along with ulcers and spots, blue in color, along your tongue and the insides of your cheeks.

Topical corticosteroid phobia in atopic dermatitis: a study of its nature, origins and frequency

BackgroundTopical corticosteroids remain the mainstay of atopic dermatitis therapy. Many atopic dermatitis therapeutic failures appear to be attributable to poor adherence to treatment due to topical corticosteroid phobia.

ObjectivesThis study was undertaken to assess the facets, origins and frequency of fear of topical corticosteroid use among atopic dermatitis patients.

MethodsA questionnaire comprising 69 items, generated from information gathered during interviews with 21 patients and 15 health professionals, was given to consecutive patients consulting at the outpatient dermatology departments of five regional university hospitals or with 53 dermatologists in private practice.

ResultsA total of 208 questionnaires were analyzed (144 were parents, and 87 adult parents and patients): 80·7% of the responders reported having fears about topical corticosteroids and 36% admitted nonadherence to treatment. A correlation was found between topical corticosteroid phobia and the need for reassurance, the belief that topical corticosteroids pass through the skin into the bloodstream, a prior adverse event, inconsistent information about the quantity of cream to apply, a desire to self-treat for the shortest time possible or poor treatment adherence. Topical corticosteroid phobia was not correlated with atopic dermatitis severity.

ConclusionTopical corticosteroid phobia is a genuine and complex phenomenon, common among French atopic dermatitis patients, that has an important impact on treatment compliance.

British Journal of Dermatology, 06/21/2011



A 20 year old student complained of itchy, red, painful rashes at his neck and trunk after his field trip to the New Territories. He discovered a caterpillar under his shirt.


Examination showed multiple erythematous macules, papules and wheals at the right side of his neck and trunk as shown in the picture.
'Dr, are the rashes due to the caterpillar?'



Do you think the rashes were caused by the caterpillar?



How would you manage this patient?





Yes. His rashes were typical of that caused by caterpillars. Caterpillars can cause dermatitis by a) direct irritation by its hairs and b) toxins in the hairs. Clinically, they present as itchy, sometimes painful, red macules, papules and wheals. Hairs stuck in the clothing can give rise to wide-spread lesions.


The management should consists of:
a) topical steroid is usually adequate. In severe and wide-spread cases, a short course of low dose systemic steroid (prednisolone 20-40 mg q.d.) may be given.
b) contaminated clothing is better discarded because caterpillar hairs may remain in it.


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