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Introduction: There are an increasing number of biologic drugs in the pipeline for treating hidradenitis suppurativa (HS). Clinical trials for these drugs usually share the same clinical selection criteria., Objectives: (a) To describe the clinical profile of HS patients receiving first-line biologic treatment in an HS clinic setting, (b) to assess how this population would meet clinical criteria to participate in a clinical trial, and (c) to assess treatment effectiveness at week 16 in eligible vs non-eligible patients., Methods: Prospective observational study. Patients were grouped according to their eligibility for clinical trials. The effectiveness of adalimumab was assessed by HiSCR, IHS4-category-change and a-50%-reduction on IHS4 at week 16., Results: Thirty-eight patients were included in the study: eight (21.05%) were eligible for clinical trials and 30 (78.95%) were not. The main reason for non-eligibility was not having an AN count ≥5. Both groups presented similar number of draining tunnels. Effectiveness at week 16 was lower in non-eligible than eligible patients when evaluated by HiSCR-response but similar if evaluated by the IHS4-category-change or the 50%-reduction in IHS4., Conclusion: In our population, the external validity of current eligibility criteria for clinical trials is low. Most patients receiving adalimumab in real-life setting would not be eligible for clinical trials., (© 2020 Wiley Periodicals LLC.)

This review aims to be an update of Bioengineered Artificial Skin Substitutes (BASS) applications. At the first moment, they were created as an attempt to replace native skin grafts transplantation. Nowadays, these in vitro models have been increasing and widening their application areas, becoming important tools for research. This study is focus on the ability to design in vitro BASS which have been demonstrated to be appropriate to develop new products in the cosmetic and pharmacology industry. Allowing to go deeper into the skin disease research, and to analyze the effects provoked by environmental stressful agents. The importance of BASS to replace animal experimentation is also highlighted. Furthermore, the BASS validation parameters approved by the OECD (Organisation for Economic Co-operation and Development) are also analyzed. This report presents an overview of the skin models applicable to skin research along with their design methods. Finally, the potential and limitations of the currently available BASS to supply the demands for disease modeling and pharmaceutical screening are discussed., Competing Interests: The authors declare no conflict of interest.

The aim of this study was to analyse the levels of anxiety, depression, and quality of life of individuals living with acne patients (cohabitants). The study included patients, cohabitants, and controls; a total of 204 participants. Patients' health-related quality of life was measured with the Dermatology Life Quality Index (DLQI), while cohabitants' quality of life was measured with the Family Dermatology Life Quality Index (FDLQI). The psychological state of all participants was measured with the Hospital Anxiety and Depression Scale (HADS). Presence of acne impaired the quality of life of 89.4% of the cohabitants. The FDLQI scores of cohabitants were significantly associated with the DLQI scores of the patients (rp = 0.294; p = 0.044). Anxiety and depression levels in cohabitants were significantly higher than in controls (p < 0.01). In conclusion, acne may have a negative impact on quality of life and psychological well-being of patients and their cohabitants.

Background: Ultrasonography can improve disease severity assessment in hidradenitis suppurativa (HS) patients. The use of pre-operative ultrasonography could improve surgical outcomes in HS patients., Objectives: (i) To assess changes in the projected skin-excised area after the use of pre-operative ultrasonography, (ii) to explore the clinical factors potentially associated with inaccurate clinical surgical delimitation and (iii) to compare recurrence rates after pre-operative ultrasound vs clinical surgical margin delimitation at week 24., Methods: Cohort study. Patient candidates for surgical treatment by wide excision and healing by secondary intention with a clinical projected skin-excised area equal to or larger than 15 cm 2 were included. The main variables of interest were the clinical and ultrasound projected skin-excised area and surgical recurrence., Results: Pre-operative ultrasound surgical margin delimitation increased the mean excised area by 3.67 (SD 0.86) cm 2 , P = 0.004. The Bland-Altman plot showed that in 65% of surgical procedures the use of ultrasonography increased the projected skin-excised area. Higher IHS4 scores, BMI, male sex and Hurley stage II vs III all increased the difference between clinical and ultrasound surgical delimitation. At week 24, the recurrence rate in the surgical clinical delimitation cohort was 30% compared to 10% in the cohort with pre-operative ultrasonography (P = 0.10)., Conclusions: Pre-operative ultrasonography improves surgical margin delimitation and can lower recurrence rates at 24 weeks in HS patients. Potential risk factors for inaccurate clinical surgical delimitation are obesity, male sex, Hurley II stage and elevated IHS4 scores, so special attention should be given to these patients when ultrasonography is not available and surgical delimitation is based only on clinical examination., (© 2020 European Academy of Dermatology and Venereology.)

Background: There is not an ideal biomaterial for tissue-engineered skin substitutes (TESSs), and most of the studies or existing therapies use xenogeneic origin natural biomaterials or biosynthetic scaffolds., Objective: To analyse clinical, histological integration and homeostasis parameters of a human TESS manufactured with fibrin-hyaluronic acid biomaterial (HA-Skin), grafted in immunodeficient mice for 8 weeks, and compared with the gold standard treatment (Autograft), a human TESS manufactured with fibrin-agarose biomaterial (AG-Skin) and secondary wound healing dressings., Methods: Human TESSs and autografts were implanted into BALB/c mice after surgical excision. Secondary wound healing approach was achieved with biosynthetic collagen wound dressing (Biobrane ® ) and fibrin-hyaluronic acid or fibrin-agarose biomaterial without cells (Total N = 44). Clinical integration and homeostasis parameters were evaluated every two weeks for two months. Histological and immunohistochemical analyses were performed four and eight weeks after grafting., Results: HA-Skin, AG-Skin and Autograft groups showed a proper clinical integration and epithelization eight weeks later. Scar evaluation revealed better results for Autograft and HA-Skin. Homeostasis analysis indicated similar values of transepidermal water loss and elasticity between HA-Skin (6.42 ± 0.75 g/h/m 2 , 0.42 ± 0.08 AU), Autograft (6.91 ± 1.28 g/h/m 2 , 0.40 ± 0.08 AU) and healthy mouse skin (6.40 ± 0.43 g/h/m 2 , 0.35 ± 0.03 AU). Histological results showed that human TESSs and autografts presented better skin structuration and higher expression of cytokeratins., Conclusions: This study suggests that human TESS based on fibrin-hyaluronic acid biomaterial could be suitable for clinical application in the treatment of several dermatological pathologies (wound healing)., (© 2020 European Academy of Dermatology and Venereology.)

Skin cancer prevention campaigns in schools have been shown to be both effective and cost-effective. The success of such programs depends on the use of an appropriate design informed by a prior survey of the target population (pupils, teachers, and parents). There are, however, very few validated Spanish-language questionnaires designed to study the habits and knowledge of this population with respect to sun exposure in childhood and none designed for use with a young adult population., Objectives: To construct and validate a questionnaire designed to explore sun exposure behaviors in a young adult population., Methodology: Two questionnaires were developed, one for adults (18+) and the other for young adults (11-17); both included demographic information, skin color, Fitzpatrick skin type, and history of sunburn as well as questions on knowledge, attitudes and practices related to sun exposure. The content was then piloted and its validity analyzed. The subsequent validation study was divided into 2 phases as follows: 1) analysis of the validity and internal consistency of the items in a cross-sectional study of 1,482 adults and adolescents, using exploratory factor analysis to test construct validity and Cronbach α to measure internal consistency; and 2) evaluation of test-retest reliability in 39 individuals., Results: The pilot study demonstrated the content validity of both questionnaires. Principal component analysis revealed that 2 components in each of the dimensions studied accounted for over 50% of the variance. A good correlation was found between the items studied. Validity was demonstrated in the first phase of the analysis with a Cronbach α of between 0.45 and 0.8 for all components except knowledge (0.335). In the second phase, test-retest reliability was demonstrated (absolute agreement>60%)., Conclusions: The psychometric properties of the questionnaire make it a valid and reliable tool for the study of knowledge, attitudes, and habits with respect to sun exposure in the young adult school population., (Copyright © 2020 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that impairs patients' physical and mental health. However, few studies have considered the consequences of HS on cohabitants. The aims of this study were to explore the impact of HS on the quality of life (QOL) of cohabitants and to assess potentially associated factors. A cross-sectional study was conducted and patients with HS and their cohabitants were invited to participate. Validated questionnaires were used to measure QOL, anxiety and depression, type D personality and sexual dysfunction. The clinical variables of patients and the demographic characteristics of cohabitants were also collected. Twenty-seven patients and 27 cohabitants were included for analysis. Patients and cohabitants presented significant QOL impairment. A direct association was found between the Dermatology Life Quality Index (DLQI) and the Familiar Dermatology Life Quality Index (FDLQI). DLQI scores were associated with the presence of negative affectivity, a trait typical of type D personality, as well as with cohabitants' anxiety. FDLQI scores were associated with cohabitant anxiety and patient depression. Hidradenitis suppurativa damages quality of life in patients and cohabitants. Identifying potential psychological factors could help us to recognize at-risk patients and apply personalized treatments for them and their environment.

Corticosteroid infiltrations of lesions in hidradenitis suppurativa (HS) appear to be beneficial to acute flares. The aim of this study is to evaluate the effectiveness and safety of ultrasound-assisted intralesional corticosteroid infiltrations to HS lesions. Prospective cohort study between February 2017 and February 2019 on patients with mild to severe HS and one or more inflammatory lesions. The study intervention was ultrasound-assisted intralesional infiltration of triamcinolone acetonide 40 mg/ml. The main outcome was the complete response rate of infiltrated lesions versus non-infiltrated lesions. Two hundred and forty-seven infiltrated inflammatory lesions and 172 non-infiltrated lesions were included. At week 12, 81.1% (30/37) of nodules, 72.0% (108/150) of abscesses and 53.33% (32/60) of draining fistulas presented complete response versus 69.1% (47/68), 54.3% (38/70) and 35.3% (12/34) respectively for the non-infiltrated lesions. The Hurley stage negatively correlated with complete response for abscesses and draining fistulas at - 0.17 (SD 0.06) p < 0.01 and - 0.30 (SD 0.13) p < 0.02 respectively. Ultrasound-assisted corticosteroid infiltration is a useful technique for the treatment of inflammatory HS lesions, with high and sustained response rates, especially for abscesses and small to medium-size simple draining fistulas. The likelihood of response correlates negatively with the Hurley stage.

Nodular lichen myxoedematosus is a localised form of lichen myxoedematosus, a chronic idiopathic cutaneous mucinosis of known aetiology. Ustekinumab is a human interleukin-12/23 monoclonal antibody that could directly or indirectly increase mucin production. Herein, we report for the first time a case of nodular lichen myxoedematosus associated with ustekinumab., (© 2020 The Australasian College of Dermatologists.)

Background: Alopecia areata (AA) is a skin disease that produces hair loss in patches of skin. The underlying mechanism of AA is a loss of immune privilege of hair follicles, which are then attacked by natural killer (NK) cells. A previous genome-wide association study linked single nucleotide polymorphisms of the protein MHC class I chain-related A (MICA) to this disease. MICA is the ligand for the activating receptor NKG2D, expressed mainly by NK cells and CD8+ cytotoxic T cells. As the aforementioned study did not include short tandem repeats (STRs) of MICA, we decided to study these in relation to AA., Aim: To study the association of STRs with AA, alongside that of human leucocyte antigen (HLA) locus B, which is closely linked to MICA., Methods: DNA amplicon size analysis was carried out, and HLA-B locus genomic typing was performed by PCR-sequence-specific oligonucleotide analysis., Results: We observed an association between AA and both MICA*009 and HLA-B14; associations were also observed between HLA-B alleles and MICA alleles, which have both been previously found to be connected with AA, but never studied together., Conclusions: We conclude that it is important to study HLA-B and MICA together to avoid the influence of their association in experiments in which they are investigated separately., (© 2020 British Association of Dermatologists.)

The aim of this study was to determine the prevalence and type of cutaneous manifestations which occur in patients with granulomatosis with polyangiitis and to explore the potential association between cutaneous and systemic involvement in these patients. A retrospective case series study was designed, including all granulomatosis with polyangiitis cases diagnosed between 2010 and 2018 at the Hospital Universitario Virgen de las Nieves. Thirty-nine patients with granulomatosis with polyangiitis were identified, of which 53.85% presented cutaneous manifestations. In decreasing order of frequency, the types of cutaneous problems observed included: palpable purpura, mucocutaneous ulcers, subcutaneous nodules, pyoderma gangrenosum-like ulcers, digital necrosis, papulonecrotic lesions and livedo reticularis. Patients with palpable purpura presented a higher frequency of renal involvement (p = 0.008). Cutaneous manifestations of granulomatosis with polyangiitis may facilitate early disease diagnosis. Likewise, a manifestation such as palpable purpura may be a predictor of kidney damage.

To characterize the exposome of the Spanish population and its association with skin ageing a cross-sectional epidemiological study was conducted in men and women (18-60 years old). A total of 1,474 participants were included. Mean age (± standard deviation) was 40.84 ± 10.26 years. Most participants had Fitzpatrick skin phototype II (44.1%) and skin ageing in accordance with their current age (69.0%). In the logistic model, age, smoking habit, use of sunscreen and use of cosmetics were all significant independent predictors of skin ageing. Thus, tobacco consumption increased the score of the model towards presenting skin ageing above that expected for age, while the opposite occurred with the use of sunscreen and a complete skin care routine. The exposome therefore has an impact on skin ageing, with age, smoking habit, use of sunscreen and the use of cosmetics identified as predictors of skin ageing. Skin care routines and sunscreen use may help to prevent this process.

The presence of eczema and elevated IgE in pediatric patients does not always indicate atopic dermatitis. Rare genodermatoses may share this clinical presentation and should be considered in the differential diagnosis for patients with congenital immunodeficiency and severe refractory dermatitis. We describe a case of severe dermatitis, allergies, and metabolic wasting syndrome, due to a novel mutation in DSG1 gene, an additional example of this uncommon genetic disorder of desmosome function., (© 2020 Wiley Periodicals, Inc.)

Background: Snow reflectivity and altitude increase the exposure of ski resort workers to solar ultraviolet radiation. The aim was to assess the presence of skin cancer in ski resorts workers and compare it with other groups of outdoor workers reviewing published studies., Methods: An observational cross-sectional prospective study was conducted in the three largest ski resorts in Spain: Baqueira Beret, Lleida; Formigal, Huesca and Sierra Nevada, Granada. All outdoor workers including ski instructors were invited to participate in the study. The participants completed a validated questionnaire about sun exposure and underwent a skin examination., Results: 219 workers were included in the study (80% male; mean age 43.8 (SD 11.31) years). Actinic keratosis (AK) but no other skin cancers were detected in 32 participants (14.62%). Those with AK worked in the Southernmost ski resort, were more likely to have light colour hair, and were older and with higher photoaging grade than those without them., Conclusion: Compared to other studies, outdoor workers on ski resorts show a higher prevalence of AK than general population but a lower prevalence than other groups of outdoor workers., Competing Interests: The authors did not have any specific conflicts of interest related to this study., (Copyright © 2020 Yolanda Gilaberte et al.)

Background/aims: TNF-α inhibitors represent the most advanced approved therapeutic option for moderate and severe forms of hidradenitis suppurativa (HS). However, in recent years, cases of paradoxical HS secondary to the use of these biological drugs have been described, with very few cases reported in the literature. The aims of this study are (1) to present 2 new cases of paradoxical HS and (2) to perform a systematic review of scientific evidence regarding paradoxical HS with TNF-α inhibitors., Material and Methods: This is a retrospective study in which we searched all the cases of paradoxical HS secondary to the use of TNF-α inhibitors published in the literature and included two additional cases observed in our clinical practice., Results: A total of 34 patients under TNF-α inhibitor treatment were included (adalimumab = 21; infliximab = 9; etanercept = 4). The median delay from exposure to TNF-α inhibitor and the development of paradoxical HS was 12 months (range 1-72). The majority of patients were Hurley stage II (58.8%). Clinical improvement and complete remission were more frequent when the TNF-α inhibitor was stopped or switched to another biological agent with a different therapeutic target rather than maintenance or change to another TNF-α inhibitor., Conclusions: Paradoxical HS is an unusual adverse effect of TNF-α inhibitors. When this adverse effect appears, interruption or substitution of treatment is associated with a better clinical outcome., (© 2020 S. Karger AG, Basel.)

Purpose of Review: To provide an update of vascular malformation syndromes by reviewing the most recent articles on the topic and following the new International Society for the Study of Vascular Anomalies (ISSVA) 2018 classification., Recent Findings: This review discusses the main features and diagnostic approaches of the vascular malformation syndromes, the new genetic findings and the new therapeutic strategies developed in recent months., Summary: Some vascular malformations can be associated with other anomalies, such as tissue overgrowth. PIK3CA-related overgrowth spectrum (PROS) is a group of rare genetic disorders with asymmetric overgrowth caused by somatic mosaic mutations in PI3K-AKT-mTOR pathway that encompass a heterogeneous group of rare disorder that are associated with the appearance of overgrowth. CLOVES syndrome and Klippel-Trénaunay syndrome are PROS disease. Proteus syndrome is an overgrowth syndrome caused by a somatic activating mutation in AKT1. CLOVES, Klippel-Trénaunay and Proteus syndromes are associated with high risk of thrombosis and pulmonary embolism. Hereditary hemorrhagic telangiectasia is an autosomic dominant disorder characterized by the presence of arteriovenous malformations. New therapeutic strategies with bevacizumab and thalidomide have been employed with promising results.

Background: Knowledge of seasonal variation of cutaneous disorder may be useful for heath planning and disease management. To date, however, descriptions of seasonality including all diagnoses in a representative country sample are very scarce., Objectives: To evaluate if clinical dermatologic diagnosis in Spain change in the hot vs. cold periods., Materials and Methods: Survey based on a random sample of dermatologists in Spain, stratified by area. Each participant collected data during 6 days of clinical activity in 2016 (3 in the cold period of the year, 3 in the hot period). Clinical diagnoses were coded using ICD-10., Results: With a 62% response proportion, we got data on 10999 clinical diagnoses. ICD-10 diagnostic groups that showed changes were: other benign neoplasms of skin (D23), rosacea (L71) and other follicular disorders (L73), which were more common in the hot period and acne (L70) which was more frequent in the cold period. We describe differences in the paediatric population and in private vs. public practice. Some of these differences might be associated to differences in the population demanding consultations in different periods., Conclusions: The frequency of most clinical diagnosis made by dermatologists does not change over the year. Just a few of the clinical diagnoses made by dermatologists show a variation in hot vs. cold periods. These variations could be due to the diseases themselves or to seasonal changes in the demand for consultation., (Copyright © 2019 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

A new model of tissue-engineered artificial autologous human skin developed in Andalusia is currently being transplanted into patients suffering from large burns within the Andalusian Public Healthcare System. This product is considered an advanced therapy medicinal product (ATMP) in Europe, and its clinical use implies meeting transplant and medicinal product legal requirements, being the Guidelines of Good Manufacturing Practice for ATMPs of particular importance. The preclinical research and clinical translation of the product have represented a technical, regulatory, and organizational challenge, which has taken 10 years since the first preclinical experiments were designed. Twelve patients with large burns, including 3 pediatric patients, have hitherto received artificial autologous skin grafts with an overall survival rate of 75% and positive clinical, homeostatic, and histologic results. Achieving such a milestone within our Healthcare System was possible through a multidisciplinary approach and the joint efforts of multiple publicly funded institutions and units under the coordination of the Andalusian Initiative for Advanced Therapies. In this article, we present the organizational model set up to facilitate collaboration and logistics among the professionals involved, totaling more than 80 people. The similarities between the tissue-engineered artificial autologous human skin transplant and other organ and tissue transplants, in terms of logistic requirements, reveal how regional and hospital transplant coordination have played a crucial role., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Frontal fibrosing alopecia has been related to some autoimmune diseases, but the association with rosacea is not clear. The objective of this study was to analyse the prevalence of rosacea in a group of patients with frontal fibrosing alopecia. A cross-sectional study, including 99 women with frontal fibrosing alopecia and 40 controls, was performed, in which clinical, dermoscopic and hormonal data were analysed. Women with frontal fibrosing alopecia presented a higher prevalence of rosacea than the controls did (61.6% vs. 30%, p = 0.001), especially those with severe grades of alopecia (77.8% in grade V vs. 33.3% in grade I, p = 0.02). Binary logistic multivariate analysis showed that perifollicular erythema (odds ratio (OR) 8.5; 95% confidence interval (95% CI) 1.73-42.30), higher body mass index (OR 1.16; 95% CI 1.01-1.34) and lower progesterone levels (OR 0.15; 95% CI 0.028-0.89) were associated with a higher risk of rosacea in patients with frontal fibrosing alopecia. In conclusion, patients with frontal fibrosing alopecia presented a higher prevalence of rosacea than did controls. Perifollicular erythema, higher body mass index and lower progesterone levels were associated with a higher risk of rosacea in the group with frontal fibrosing alopecia.

Background and Objective: Skin lesions are a common reason for consulting a primary care physician. Current legislation in Spain states that purely aesthetic skin problems that do not pose a health problem are not to be treated within the National Health Service. The aim of this study was to estimate the proportion of referrals from primary care physicians to dermatologists that were for cystic lesions or benign tumors and could potentially have been avoided., Material and Methods: We consulted cases registered in the DIADERM study dataset, which is representative of dermatology practice in Spain, and collected the main diagnoses given on referring patients from primary care. A referral diagnosis was classified as potentially avoidable if it corresponded to one of the primary care discharge diagnoses listed in a consensus paper of the Andalusian section of the Spanish Academy of Dermatology and Venereology (AEDV)., Results: We collected 2171 main reasons for first-visit referrals to dermatologists; 686 of them (31.6%) were for cystic lesions or benign tumors and classified as potentially avoidable. In 478 cases (22%) the patients were discharged on the first visit. The most frequent diagnoses in such cases were seborrheic keratosis (9.3%) and melanocytic nevus (8.6%)., Conclusions: Nearly a third of referrals from primary care to a dermatologist were for cystic lesions and benign tumors and could have been avoided. A clearer understanding of our caseload can be useful for improving planning, training, and health care system management., (Copyright © 2019 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background/objectives: The aetiology of frontal fibrosing alopecia is unknown, and its genetic aspect remains uncharacterised. The aim of this report is to elucidate if major histocompatibility complex is associated with familial frontal fibrosing alopecia., Methods: A case-control study was performed of 13 patients with frontal fibrosing alopecia belonging to six families. Their human leukocyte antigen profiles were compared to the data of 636 healthy controls without frontal fibrosing alopecia. Patients underwent high-resolution genomic typing for human leukocyte antigen class I and II loci by PCR-SSO for Luminex. In addition, CYP21A2 gene (major histocompatibility complex class III) mutations were detected by PCR-SSO on strips., Results: 61.5% of patients shared CYP21A2 gene p.V281L linked to the F16A human leukocyte antigen class I haplotype (HLA-A*33:01; B*14:02; C*08:02; Pc < 0.000001). The patients F16A-negative shared other human leukocyte antigen class I haplotypes: Y16A (3/13) and S26 (2/13)., Conclusion: CYP21A2 gene p.V281L mutation can be used as a genetic marker for susceptibility to familial frontal fibrosing alopecia. Both the linkage of the mutation to F16A and the fact that F16A-negative patients share other human leukocyte antigen class I haplotype, point to an antigen-driven mechanism in susceptible patients with these haplotypes., (© 2019 The Australasian College of Dermatologists.)

In recent years, the growing interest in the role played by vitamin D in skin disease has given rise to the publication of many studies of the relationship between this vitamin and certain skin conditions. As dermatologists, we need to understand, among other aspects, how vitamin D is synthesized and the main sources in humans, as well as plasma levels and the factors that can modify them. Of particular interest are the latest discoveries about the role of vitamin D in skin diseases such as lupus erythematosus, ichthyosis, atopic dermatitis, hidradenitis suppurativa, acne, alopecia areata, androgenetic alopecia, melanoma, and nonmelanoma skin cancer. Also of interest is the importance of vitamin D as adjuvant therapy in patients on long-term treatment with corticosteroids. In this review, we provide an overview of the most important and most recent information regarding the relationship between vitamin D and skin disease and discuss the importance of assessing individual vitamin D status and correcting deficiencies., (Copyright © 2018 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background/objectives: Frontal fibrosing alopecia (FFA) is a scarring alopecia whose prevalence is increasing. The pathogenesis of this disease is not well known. Genetic, environmental, hormonal and autoimmunity related factors have been considered; however, only a few cases of familial frontal fibrosing alopecia have been reported., Material and Methods: A cross-sectional study was performed at University Hospital in Granada (Spain). Twenty patients with frontal fibrosing alopecia belonging to nine different families were included, and clinical and dermoscopic features were analysed., Results: Overall, 90% of the patients studied were women (mean age 61.4 years). About 50% of the patients had grade II frontal fibrosing alopecia at the time of diagnosis, whilst 35% had grades III or V. Mean recession was 2.83 cm in the frontal area and 1.99 cm in the temporo-parietal area. Daughters presented a shorter recession area and earlier debut of the disease than mothers. Androgenetic alopecia was found in only two patients (10%). The dermoscopic signs most commonly found were perifollicular erythema (85%), hyperkeratosis (85%), and absence of vellus hair in the hairline (78.9%)., Conclusion: This study adds to the growing evidence that there is a genetic component to frontal fibrosing alopecia. The clinical pattern of frontal fibrosing alopecia was not different from that found in non-familial cases, but the debut of the disease in daughters of mothers with frontal fibrosing alopecia may be earlier., (© 2018 The Australasian College of Dermatologists.)

Background and Objectives: Understanding the origin and referral routes of patients seen in teledermatology and in-person dermatology consultations in Spain is of interest from the perspective of health care management. The objective of this study was to describe the referral routes and the frequency and characteristics of teledermatology consultations in Spain., Material and Methods: We performed a descriptive cross-sectional study of data collected over 6 days from the DIADERM study sample, which included the outpatients diagnosed by 80 Spanish dermatologists, selected by means of stratified random sampling. We studied the source and destination of patients based on funding, type of consultation, and age of the patients. We reported the frequency of teledermatology consultations, their origin and destination, type of funding, age of the patients, and most common diagnoses, and compared them with the same characteristics for in-person consultations., Results: In private consultations, most patients were direct clients, whereas the most frequent source in public consultations was primary care and the dermatologist. Sixty-six percent of patients were referred to dermatology and 27% were discharged. No differences in these percentages were found between public and private consultations. The ratio of follow-up to initial visits was 0.8 for public consultations and 0.2 for private consultations. Teledermatology accounts for 1% of consultations. Eighty percent of these come from primary care and 17% are direct visits. Thirty-three percent of these visits are referred to primary care - a greater proportion than in in-person consultations. Galicia, Andalusia, and Catalonia are the regions with the highest percentage of consultations., Conclusions: The results suggest that dermatologists in Spain have a considerable ability to resolve cases. Teledermatology accounts for a small percentage of consultations and access to these consultations is direct in a large percentage of cases., (Copyright © 2018 AEDV. All rights reserved.)

Background/purpose: Psoriasis is a multisystem disease which has been related to vitamin-D deficiency through chronic inflammation. This psoriasis-related inflammatory state and vitamin-D deficiency may induce bone mineral density loss. The purpose of this study is to assess the relationship of psoriasis with bone mineral density, by comparing psoriatic patients with healthy controls and patients with osteopenia/osteoporosis., Methods: A total of 185 subjects were studied; 58 psoriatic patients who had not been under systemic or biological treatment were included. Age, gender, body mass index, phosphocalcic metabolic parameters and hip and lumbar (L4) bone mineral density data were collected. These variables were compared with those collected in 61 healthy controls and 67 patients with osteopenia/osteoporosis., Results: Psoriatic patients showed worse hip and lumbar spine bone mineral density levels than healthy controls (P = 0.001) and better levels than osteoporotic patients (P < 0.001). Multivariate analysis demonstrated a negative association of age and a positive association of body mass index in hip bone mineral density in psoriatic patients., Limitations: The main limitations are those of cross-sectional studies, such as a lack of follow up period, and a male predominance in the psoriatic group, which is corrected employing a multivariate analysis with an adjusted model for confounding factors., Conclusions: Bone mineral density levels in psoriatic patients are situated halfway between healthy controls and patients with osteopenia/osteoporosis. In addition, the higher body mass index in patients with psoriasis appears to confer a protective effect against further development of lower bone mineral density., Competing Interests: None

Background: Psoriasis is associated with an increased risk of cardiovascular disease (CVD) at younger ages that is not identifiable by traditional risk factors. Screening for subclinical atherosclerosis with ultrasound has only been investigated in carotid arteries. Femoral artery ultrasound has never been considered for this purpose. The link between psoriasis and accelerated atherosclerosis has not yet been established., Objective: To study the usefulness of femoral artery ultrasound for the detection of subclinical atherosclerosis in psoriasis. We also investigated its possible relationship with changes in insulin resistance., Methods: We conducted a cross-sectional study in 140 participants, 70 patients with moderate-to-severe psoriasis and 70 healthy controls, matched 1:1 for age, sex, and BMI. Femoral and carotid atherosclerotic plaques were evaluated by ultrasonography. Insulin resistance was assessed by the homeostasis model assessment method (HOMA-IR)., Results: Femoral atherosclerotic plaque prevalence was significantly higher in patients with psoriasis (44.64%) than in controls (19.07%) (p<0.005), but no significant difference was found in carotid plaque prevalence (p<0.3). Femoral plaques were significantly more prevalent than carotid plaques (21.42%) among patients with psoriasis (p<0.001). In the regression analysis, insulin resistance was the most influential determinant of atherosclerosis in psoriasis and C-reactive protein the most significant predictor of insulin resistance., Conclusions: Ultrasound screening for femoral atherosclerotic plaques improves the detection of subclinical atherosclerosis in patients with psoriasis, whereas the study of carotid arteries is not sufficiently accurate. Insulin resistance appears to play a greater role in the development of atherosclerosis in these patients in comparison to other classical CVD risk factors., Competing Interests: The authors have declared that no competing interests exist.

Importance: Sexual health is a major aspect of life. Increasing scientific evidence shows a potential association between psoriasis and sexual dysfunction (SD) and erectile dysfunction (ED)., Objective: To evaluate the available scientific evidence regarding epidemiologic associations and treatment outcomes between psoriasis and SD and ED., Evidence Review: Information sources were MEDLINE and Embase databases, using the Scopus search engine. The search was performed on August 25, 2017. Search terms were psoriasis and sexual or sexual dysfunction, and the search was limited to epidemiologic studies published in English answering any of the 4 research questions. Quality was assessed according to the Centre for Evidence-Based Medicine., Findings: Twenty-eight studies representing 52 520 cases of psoriasis and 1 806 022 controls were included for review. Of the 28 studies, 19 were cross-sectional, 3 were clinical trials, 3 were quasi-experimental, 2 were population-based cohort, and 1 was population-based case-control. Prevalence of SD and ED ranged from 40.0% to 55.6% and 34.2% to 81.1%, respectively. Two of 2 studies observed an association between psoriasis and SD after adjusting for physical and psychological comorbidities. Five of 8 studies observed an independent association between ED and psoriasis. Among patients with psoriasis, the features that showed the strongest association with SD were anxiety and depression (5 of 5 studies), psoriatic arthritis (3 of 4 studies), and genital psoriasis (5 of 7 studies). Regarding ED, anxiety and depression (2 of 2 studies) and increasing age (3 of 3 studies) showed the strongest association. All 3 clinical trials using biologic drugs showed an improvement in SD compared with placebo., Conclusions and Relevance: Patients with psoriasis have physical and psychological comorbidities that have been associated with a higher risk of SD. In addition, psoriasis may play a role in its development. The presence of anxiety, depression, psoriatic arthritis, genital lesions, and increasing age should raise the awareness of SD. Biologic drugs have demonstrated the improvement of SD in patients with psoriasis.

Background: Folliculitis decalvans (FD) is a rare neutrophilic cicatricial alopecia that poses a therapeutic challenge., Objectives: To describe the therapeutic response in a large number of cases of FD with long-term follow-up and analyze potential prognostic factors associated with severity of form and with a better therapeutic response., Methods: This multicenter prospective study included patients with FD who had a minimum of 5 years of follow-up. Severity was assessed by the maximum diameter of the cicatricial area. Therapeutic response was evaluated according to stabilization of the size of the cicatricial areas and the improvement in clinical symptoms., Results: A total of 60 patients (37 men [61.7%] and 23 women [38.3%]) with a mean age of 40 years were included. Earlier age of onset (P = .01) was statistically associated with severity of form. Treatment with rifampicin and clindamycin, tetracyclines, and intralesional steroids was the most effective. No statistically significant prognostic factors predicting a better therapeutic response were found., Limitations: Because FD is a rare disease, the main limitation was the sample size., Conclusions: An earlier age of onset was associated with the severe form of the disease. The proposed specific therapeutic protocol can be a very useful tool in clinical dermatologic practice., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Psoriasis has been related to a large number of cardiovascular risk factors such as hypertension, diabetes mellitus and arteriosclerosis. The increased carotid intima-media thickness (IMT) could be considered to be a marker of generalized arteriosclerosis., Objective: To assess the effect of systemic and biological drugs on psoriatic patients' carotid IMT., Methods: A prospective study was performed. We studied 53 patients with moderate and severe psoriasis from our psoriasis dermatological unit, analysing lipid and glucose metabolism and performing a carotid IMT sonography before introduction of systemic and biological drugs. After that, we performed an 8-month closely analytic and sonographic follow-up., Results: The IMT of the patients with psoriasis treated with biological drugs tended to decrease, although this occurrence was not statistically significant (P = 0.086). The subgroup analysis revealed that patients treated with methotrexate (P = 0.045) and anti-IL-12/23 (P = 0.010) presented a decrease in their IMT levels. This analysis also showed a decrease in glycaemia and insulin levels in patients treated with TNF-alpha inhibitors and ustekinumab., Conclusions: Our study suggests that the carotid IMT may benefit from treatment with biological drugs, particularly anti-IL-12/23 and methotrexate in patients suffering from moderate and severe psoriasis. However, larger longitudinal studies should be performed to fully confirm these results., (© 2018 European Academy of Dermatology and Venereology.)

We report the high susceptibility of several clinical isolates of Propionibacterium acnes from different sources (skin, bone, wound exudates, abscess or blood contamination) to the head-to-tail cyclized bacteriocin AS-48. This peptide is a feasible candidate for further pharmacological development against this bacterium, due to its physicochemical and biological characteristics, even when it is growing in a biofilm. Thus, the treatment of pre-formed biofilms with AS-48 resulted in a dose- and time-dependent disruption of the biofilm architecture beside the decrease of bacterial viability. Furthermore, we demonstrated the potential of lysozyme to bolster the inhibitory activity of AS-48 against P. acnes, rendering high reductions in the MIC values, even in matrix-growing cultures, according to the results obtained using a range of microscopy and bioassay techniques. The improvement of the activity of AS-48 through its co-formulation with lysozyme may be considered an alternative in the control of P. acnes, especially after proving the absence of cytotoxicity demonstrated by these natural compounds on relevant human skin cell lines. In summary, this study supports that compositions comprising the bacteriocin AS-48 plus lysozyme must be considered as promising candidates for topical applications with medical and pharmaceutical purposes against dermatological diseases such as acne vulgaris.

Introduction: Dermatologists perform most of their work in outpatient or private clinics. Data on the diagnoses made by dermatologists in these settings are lacking, however, as outpatient activity, unlike hospital activity, is difficult to code. The aim of this study was to analyze the diagnoses made by members of the Spanish Academy of Dermatology and Venereology (AEDV) at dermatology clinics in Spain., Methodology: We selected a random sample of AEDV dermatologists drawn from the AEDV list and stratified by geographic area. The selected dermatologists received instructions on how to collect the data required. Each participant recorded the diagnosis reached and other data for patients seen during 2 specified periods: 3 days in January and 3 days in May. The diagnoses were subsequently coded by a dermatologist expert in applying the International Classification of Diseases (10th revision). In view of the complex nature of the sample, data were analyzed with standard error and finite population corrections., Results: The sample consisted of 124 dermatologists. Of these, 65% participated in the first phase of the study and 59% in the second. An estimated 621 562 patients (95% CI, 368 130-874 995) visit the dermatologist every month in Spain. This is the equivalent of 28 (25-31) patients per day per clinic. The most common diagnosis recorded was actinic keratosis, followed by basal cell carcinoma and melanocytic nevus. The vast majority of visits took place at the clinic, but 1% of patients (0.3%-3%) were assessed using teledermatology., Conclusions: This is the first study in Spain to analyze diagnoses made by AEDV members at outpatient dermatology clinics. Our findings show a high volume of activity and will be useful for guiding health care planning, resource use, and future studies., (Copyright © 2018. Publicado por Elsevier España, S.L.U.)

Introduction: The shrinkage of surgical specimens (SS) is known in human skin (HS) but has not been studied in an artificial skin (AS) or mouse skin (MS)., Objectives: To quantify the degree of shrinkage of SS and establish its timing in HS and an in vitro and animal model to explore the possible causes of this phenomenon., Methodology: We collected 100 SS of HS, 50 SS of AS synthesized with fibrin-agarose biomaterials and 21 SS of MS. The width and length of specimens were measured before the surgical excision (pre-SE), at 5 minutes postsurgery (ex vivo), and after 24 hours of fixation in formalin (postfixation). Histological staining was performed to analyze the differences between HS, AS, and MS that may explain the differences in shrinkage., Results: Between pre-SE and postfixation, the width and length shrank by 16.1% and 17.1% in HS, 14.5% and 8.5% in AS, and 26.5% and 23.1% in MS (P < 0.01), respectively. Shrinkage largely occurred between pre-SE and ex vivo. Cells and interstitial fibers were scant in AS and abundant in MS., Conclusions: Almost all of the shrinkage occurred during the first 5 minutes postsurgery. According to the AS model findings, 53.6% of SS shrinkage would be explained by the action of dermal fibers and other cellular components of the dermis.

Sun exposure in childhood is the main risk determinant for skin cancer in adulthood. Several questionnaires have been used to examine behaviour patterns in terms of sun exposure in childhood, but none have been subjected to a rigorous analysis of their measurement properties. To evaluate the psychometric properties of a questionnaire adapted to investigate children's sun exposure behaviour, a two-stage validation study was carried out. First, in a transverse study, the questionnaire was administered to a sample of 333 children recruited from schools, and the validity and internal consistency were analysed. Second, 32 children recruited in a hospital setting were interviewed for the test-retest analysis. All the items in the 'Photoprotection habits' category were significantly correlated. Principal components analysis showed that two components accounted for over 53% of the variance. The Cronbach's α-coefficient was 0.63 for the first component and 0.43 for the second. In the stability analysis, the percentage of absolute agreement exceeded 70% for all the questions. The Questionnaire on Habits RElated to Sun exposure during Infancy (CHRESI) questionnaire examines sun protection habits by children. Its proven reliability, validity and stability make it a useful tool both in epidemiologic research and in the development and evaluation of campaigns to reduce the risk of skin cancer.

Mesenchymal stem cells or mesenchymal stromal cells (MSCs) are non-hematopoietic stromal cells that reside in many human organs and have been isolated from a variety of adult or fetal tissues such as adipose tissue, bone marrow and umbilical cord Wharton's jelly, among others. Because they are a heterogeneous population, International Society for Cellular Therapy has established 3 minimum criteria to characterize MSCs in vitro : i) adherence to plastic, ii) differentiation potential (osteogenic, chondrogenic and adipogenic lineages) and iii) expression of specific surface antigens (CD73+, CD90+, CD105+, CD34-, CD45-, CD11b-, CD14-, CD19-, CD79a-, HLA-DR-). Because of these characteristics, MSCs are useful for different applications and studies, most of them related with regenerative biomedicine. Epithelial in vitro differentiation of MSCs, for clinical use, is one of the main objectives in this field, due to, on the one hand, the difficulties to establish epithelial cell cultures and, on the other hand, the immunomodulatory capacity of MSCs that could increase the success of transplantation. According to this and the information compiled from bibliography, production of epithelial cells differentiated in vitro from MSCs is a complex procedure and a lot of techniques and culture media are necessary to explore. The objective of this review is to show the different methods of epithelial in vitro differentiation and remark the need to further study for being capable of establishing specific cell lines of epithelial cells differentiated from autogenic or allogenic MSCs., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Background: T1 melanoma substaging was recently modified by the American Joint Committee on Cancer (AJCC). Although sentinel lymph node (SLN) positivity is the most important prognostic factor in melanoma, there is a lack of consensus on whether SLN biopsy should be performed in patients with thin melanoma (≤1 mm)., Objective: The main aim of this study was to investigate predictors of SLN positivity in patients with thin melanoma, with a special emphasis on mitotic rate. A secondary aim was to evaluate survival in this group of patients., Materials and Methods: Retrospective multicenter observational study with analysis of age, sex, tumour location, thickness, mitotic rate, regression and microscopic satellites. Predictive factors were identified using a classification and regression tree (CART) approach. Melanoma-specific survival according to SLN status was estimated using Kaplan-Meier curves., Results: We analysed 203 patients with a melanoma ≤1 mm. Using the new AJCC staging criteria, the CART algorithm identified a 7.5% likelihood of SLN positivity in T1a patients. In the case of T1b melanoma, there was a 14.3% likelihood of SLN positivity in patients with a mitotic rate >1 mitosis/mm 2 and a 3.2% likelihood in those with ≤1 mitoses/mm 2 . None of the patients with T1b disease who had ≤1 mitoses/mm 2 and regression had SLN positivity. In T1b patients, 5-year melanoma-specific survival was 98.7% in the SLN-negative group and 75% in the SLN-positive group (P = 0.05). When stratified by mitotic rate, survival was 100% for patients with a mitotic rate of ≤1 mitoses/mm 2 and 91.4% for those with >1 mitosis/mm 2 (P = 0.022). There were no deaths in the T1a subgroup., Conclusions: Sentinel lymph node metastasis was less common in patients with T1b melanoma who had a mitotic rate of ≤1 mitoses/mm 2 . Performance of SLN biopsy should be carefully considered in this subgroup of patients, particularly considering the good prognosis., (© 2017 European Academy of Dermatology and Venereology.)

We report a case of pachydermodactyly (PDD). PDD is a benign, asymptomatic soft tissue swelling affecting the skin of the lateral aspects of the proximal interphalangeal joints of the fingers, mostly in young adolescent males. It has often been interpreted as a consequence of tic-like behavior as part of an obsessive-compulsive disorder. Although the diagnosis is essentially clinical, skin biopsy shows compact orthokeratotic hyperkeratosis, increased numbers of collagen fibers and fibroblasts, and no inflammatory changes. A rapid clinical recognition of PDD should avoid many unproductive and expensive diagnostic tests.