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Hair loss is a common problem in men and women. Correct diagnosis of hair disorders is complex and requires evaluation of clinical presentation, history, physical examination, and laboratory tests. Hair loss may be categorized as hair shaft abnormalities, permanent alopecia, or nonpermanent alopecia. Nonpermanent alopecia, the most common type, includes androgenetic alopecia, telogen effluvium, alopecia areata, and traction alopecia. The hallmark of this group is the possibility of complete regrowth with adequate treatment. [ABSTRACT FROM AUTHOR]

FUNDAMENTOS: A caracterização histológica do folículo piloso normal em humanos é escassa na literatura, considerando que o reconhecimento da arquitetura folicular normal e suas variações nas diversas áreas do couro cabeludo é fundamental para o estudo das doenças do couro cabeludo. OBJETIVOS: Analisar fragmentos do couro cabeludo normal em indivíduos de raça branca quanto à área, os diâmetros máximo e mínimo dos folículos anágenos terminais. MÉTODOS: Vinte necrópsias de indivíduos de raça branca, com idade variando de 20 a 78 anos, foram acompanhadas da coleta de biópsias por punch de 4mm de diâmetro em quatro áreas do couro cabeludo. Os casos foram divididos conforme o sexo em dois grupos, com 10 casos cada. A área e os diâmetros máximo e mínimo dos folículos anágenos terminais foram determinados por análise computadorizada das imagens de cortes transversais da microscopia óptica. Os resultados obtidos foram comparados entre os sexos e os locais de coleta. RESULTADOS: Os resultados numéricos das áreas e diâmetro máximo e mínimo são expostos e comparados. CONCLUSÃO: Não houve diferença estatisticamente significativa entre o diâmetro máximo e a área folicular nas diversas regiões do couro cabeludo; entretanto, foram evidenciadas dimensões de folículos anágenos terminais maiores no sexo masculino do que no feminino.

A lipoidoproteinose (doença de Urbach-Wiethe) é doença autossômica recessiva rara, caracterizada pela deposição progressiva de substância hialina na pele, membranas mucosas e órgãos internos. Clinicamente, os pacientes apresentam lesões papulonodulares na face, com áreas de infiltração difusa da pele principalmente nos joelhos, cotovelos e mãos; a língua apresenta consistência firme. Infiltração da laringe produz rouquidão que pode estar presente já ao nascimento. Os autores relatam dois casos dessa doença acometendo indivíduos da mesma família (irmãos).

Background: Rosacea prevalence varies worldwide and there is a lack of information in Brazil., Objectives: To describe the epidemiological profile of rosacea in subjects who consulted in dermatological outpatient clinics in Brazil., Materials & Methods: A cross-sectional study was conducted in 13 dermatological outpatient clinics across the country. Patients with rosacea diagnosis were eligible for the study according to the investigator's clinical assessment. Clinical, social and demographic data were collected. The overall and regional rosacea prevalence was calculated, and association with baseline characteristics was analysed., Results: A total of 3,184 subjects were enrolled, and rosacea prevalence was 12.7%. The southern region of Brazil presented a higher prevalence, followed by the southeast. The subjects in the rosacea group were older than those without rosacea (52.5 ±14.9 vs. 47.5 ±17.5; p<0.001). Moreover, the rosacea group was associated with Fitzpatrick's phototypes I and II, Caucasian ethnicity, a family history of rosacea, and facial erythema, however, no association with gender was found. The most prevalent clinical sign and clinical subtype in rosacea patients were erythema and erythematotelangiectatic, respectively., Conclusion: Rosacea is highly prevalent in Brazil, mostly in the southern region, associated with phototypes I and II and a family history.

Background: Frontal fibrosing alopecia (FFA) is a chronic cicatricial alopecia with unknown etiology and a worldwide rising incidence., Objective: The objective of this study was to evaluate the association of FFA with demographic and exposure factors in a Brazilian multiracial population., Methods: A multicenter case-control study was conducted in 11 referral centers throughout Brazil. The study was a case-control study that prospectively recruited 902 participants (451 patients with FFA and 451 sex-matched control individuals). Study participants completed a thorough questionnaire comprising variables grouped as baseline demographics, environmental exposure, diet, hormonal factors, allergies, and hair and skin care., Results: When adjusted by sex, age, menopause, and skin color, FFA was associated with hair straightening with formalin (odds ratio [OR], 3.18), use of ordinary (nondermatologic) facial soap (OR, 2.09) and facial moisturizer (OR, 1.99), thyroid disorders (OR, 1.69), and rosacea (OR, 2.08). Smokers (OR, 0.33) and users of antiresidue/clarifying shampoo (OR, 0.35) presented a negative association with FFA. There was no association with the use of sunscreen., Limitations: Recall bias., Conclusions: The association with moisturizers, ordinary facial soap, and hair straightening with formalin and the negative association with antiresidue/clarifying shampoo reinforce the possibility of an exogenous particle triggering FFA., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Alopecia areata is a highly frequent disease with an impact on quality of life and several treatment options with little clinical confirmatory evidence., Objective: To disseminate the recommendations of Brazilian dermatologists with expertise in the treatment of alopecia areata., Methods: Eight specialists with expertise in alopecia areata from different university centers were appointed by the Brazilian Society of Dermatology to reach a consensus on its treatment. Based on the adapted DELPHI methodology, the relevant elements were considered; then, an analysis of recent literature was carried out and the consensus was written down. Consensus on the management of alopecia areata was defined with the approval of at least 70% of the panel., Results/conclusions: Intralesional injectable corticotherapy was considered the first option for localized disease in adults. In extensive cases with signs of activity, systemic corticosteroid therapy should be considered and can be used together with immunosuppressants (corticosteroid-sparing agents). The use of an immunosensitizer (diphencyprone) is an option for stable long-term cases. Evaluation of side effects is as important as the rate of hair regrowth., (Copyright © 2020 Sociedade Brasileira de Dermatologia. Published by Elsevier España, S.L.U. All rights reserved.)

Psychologic and social effects of scalp hair are more important than its biologic significance. Etiology of alopecia areata (AA) suggests a predominantly autoimmune reaction. Correlation between AA and psychologic disorders is reciprocal. Psychiatric disorders can trigger the onset of AA and its negative consequences may develop or exacerbate psychologic problems. The high incidence of a neurotic personality, depression, anxiety, and deficiency in coping with stress strengthen the role of psychic factors in the pathogenesis of AA. Strategies to assess these patients are often not apparent for the clinician and identifying patients in need of extra psychologic support should be a mainstay for successful treatment. Women, young patients, and those with significant AA or previous psychiatric disorders are at greater risk, requiring careful monitoring. Proper awareness and consciousness about the close relationship between AA and psychologic factors are essential., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Folliculotropic mycosis fungoides (FMF) is a cutaneous T-cell lymphoma mainly affecting the hair follicle, which seems to represent a place of immune privilege phenomenon., Objectives: To explore a possible role of immune privilege (IP) in FMF analyzing the major histocompatibility complex (MHC) expression., Methods: Immunohistochemistry for HLA-G and MHC-II was performed to formalin-fixed paraffin-embedded cutaneous skin biopsies of FMF patients (n = 43), conventional mycosis fungoides (CMF; n = 13), alopecia areata (AA; n = 13), and normal scalp skin (NS; n = 12)., Results: HLA-G expression was lower in FMF (34%: 14/41) and CMF (18%: 2/11) groups compared to alopecia areata (92%:11/12) and normal scalp skin group (100%: 12/12). MHC-II expression in hair follicle was greater in the FMF group (18/42: 43%) compared to AA (0%) and NS (0%). HLA-G and MHC-II expression in cellular infiltrate had no difference among FMF and CMF groups and was different compared to the AA group., Conclusions: Our data support the hypothesis of disruption of immune privilege based on the lower expression of HLA-G and higher expression of MHC-II in the follicular epithelium in mycosis fungoides compared to alopecia areata and normal scalp skin. The lack of difference between FMF and CMF groups did not support the role of these molecules as a driver of folliculotropism. The expression of MHC molecules seems to be different between neoplastic and inflammatory infiltrates. The definitive significance of expression of the MHC molecules remains unclear, and more studies are necessary to fully understand the role of these molecules in cutaneous lymphomas., (© 2018 The International Society of Dermatology.)

Background: The current options for the treatment of acne vulgaris present many mechanisms of action. For several times, dermatologists try topical agents combinations, looking for better results., Objectives: To evaluate the efficacy, tolerability and safety of a topical, fixed-dose combination of adapalene 0.1% and benzoyl peroxide 2.5% gel for the treatment of acne vulgaris in the Brazilian population., Methods: This is a multicenter, open-label and interventionist study. Patients applied 1.0 g of the fixed-dose combination of adapalene 0.1% and benzoyl peroxide 2.5% gel on the face, once daily at bedtime, during 12 weeks. Lesions were counted in all of the appointments, and the degree of acne severity, overall improvement, tolerability and safety were evaluated in each visit., Results: From 79 recruited patients, 73 concluded the study. There was significant, fast and progressive reduction of non-inflammatory, inflammatory and total number of lesions. At the end of the study, 75.3% of patients had a reduction of >50% in non-inflammatory lesions, 69.9% in inflammatory lesions and 78.1% in total number of lesions. Of the 73 patients, 71.2% had good to excellent response and 87.6% had satisfactory to good response. In the first week of treatment, erythema, burning, scaling and dryness of the skin were frequent complaints, but, from second week on, these signals and symptoms have reduced., Conclusion: The fixed-dose combination of adapalene 0.1% and benzoyl peroxide 2.5% gel is effective, safe, well tolerated and apparently improves patient compliance with the treatment.

Background: Lichen planopilaris is a frequent presentation of primary cicatricial alopecia. Scalp distribution characterizes the main clinical presentations: classic lichen planopilaris, frontal fibrosing alopecia and Graham-Little Piccardi-Lassueur Syndrome (GLPLS)., Objective: Description of the clinical, dermoscopic and histopathological findings of Lichen planopilaris in public and private practices., Method: A retrospective observational study was performed by reviewing medical records of patients with lichen planopilaris., Results: Eighty patients were included, 73 (91,25%) were female. Prototype II was seen in 53 (66,25%) patients. Classic lichen planopilaris was seen in 62,5% of the cases. Frontal fibrosing alopecia was seen in 31% of the patients and only one patient presented Graham-Little Piccardi-Lassueur Syndrome (GLPLS). Scalp lesions were scattered throughout the scalp in 47 (58,75%) of the patients, while 24 (30%) presented mainly central scalp lesions, 29 (36,25%) presented marginal lesions and only 4 (5%) patents had vertex lesions., Conclusions: Clinical presentation of Lichen planopilaris varies. To recognize the heterogeneity of the clinical appearance in lichen planopilaris is important for differential diagnosis.

Dermatosis neglecta is the name of a skin condition characterized by papules and polygonal plaques, which are sometimes warty, brownish and hyperpigmented, adherent and symmetric, though removable with ethyl or isopropyl alcohol. It occurs due to inadequate skin cleansing causing accumulation of sebum, sweat, keratin and impurities. Its occurrence, though little reported, is frequent. The main differential diagnosis is the Terra firma-forme dermatosis. The treatment is simple, with exfoliation, moisturizing and even rubbing of alcohol. Causes of negligence on the patient's side, which can range from hygiene carelessness to psychiatric disorders, local hypersensitivity, limbs negligence or motor paralysis, should be investigated. We illustrate the case of dermatosis neglecta in a 45-years old patient admitted with pulmonary sepsis.

Background: Alopecia areata is a chronic disorder of the hair follicles and nails, of unknown etiology, with clear autoimmune components and genetic factors. Several therapeutic options have been suggested; however, no treatment is able to modify the disease course. Methotrexate is an immunosuppressant used in various dermatoses and recently introduced as a therapeutic option for alopecia areata., Objectives: To evaluate the efficacy and safety of methotrexate in alopecia areata., Methods: In a retrospective, non-controlled study, we evaluated 31 patients with alopecia areata in current or prior treatment with methotrexate to assess the therapeutic response according to sex, age, pattern of alopecia areata, disease duration, cumulative dose of methotrexate, use of systemic corticosteroids or other treatments, and drug safety., Results: Regrowth greater than 50% was observed in 67.7% of patients, with the best responses observed in those with <5 years of disease progression (79%), age over 40 years (73.3%), male patients (72.8%), cumulative dose of methotrexate 1000-1500 mg, and multifocal alopecia areata (93%). Among patients receiving systemic corticosteroids in combination with methotrexate, 77.3% had greater than 50% regrowth, compared with 44.4% in those who used methotrexate alone. The therapeutic dose ranged from 10-25 mg/week. No patient had serious adverse effects. Relapse was observed in 33.3% of patients with more than 50% regrowth., Conclusion: Methotrexate appears to be a promising and safe medication for the treatment of severe alopecia areata when used alone or in combination with corticosteroids.

Background: Forehead and glabella rhytides are treated mostly with neurotoxins, although some practitioners prefer the concurrent use of fillers. It has been suggested that combination treatments can result in a better overall improvement., Aims: To compare the safety and effectiveness of treatment of forehead and glabellar lines with botulinum toxin A alone versus botulinum toxin A and filler., Methods: Split-face, randomized control trial. Twenty subjects with forehead/glabellar rhytide complex (static and dynamic creases) enrolled. Subjects were randomized and injected with botulinum toxin alone on one side of the forehead/glabella and hyaluronic acid filler followed by botulinum toxin on the other side. Blinded ratings were obtained to assess the effectiveness of treatment for static and dynamic rhytides, respectively, at 2-week, 6-week, 3-month, and 6-month follow-up visits. Subjects performed a self-evaluation at the end of the study. Adverse events were recorded., Results: Ratings of both treatments showed comparable efficacy, with 100% of subjects experiencing improvement from baseline regardless of treatment type at weeks 2, 6, and 12. Combination treatment produced longer-lasting results in dynamic forehead wrinkles, and greater static and dynamic wrinkle reduction in the glabella at week 24. Subject self-evaluations showed that both treatments were effective, with a nominal preference for combination treatment., Conclusions: Glabella and forehead lines can be effectively and safely reduced with neurotoxin alone as well as neurotoxin in combination with fillers. Combination treatment may provide a slightly better cumulative benefit and also increase the persistence of effect., (© 2013 Wiley Periodicals, Inc.)

Ichthyoses are a common group of keratinization disorders. A non-inflammatory generalized persistent skin desquamation is observed. It is characterized by increased cell turnover, thickening of the stratum corneum and functional changes of sebaceous and sweat glands. All of these favor fungal proliferation. Dermatophytes may infect skin, hair and nails causing ringworm or tinea. They have the ability to obtain nutrients from keratinized material. One of its most prevalent genera is Trichophyton rubrum. Although tineas and ichthyoses are quite common, the association of the two entities is rarely reported in the literature. Three cases of ichthyosis associated with widespread infection by T. rubrum are presented. Resistance to several antifungal treatments was responsible for worsening of ichthyosis signs and symptoms.

Diffuse alopecia is mainly caused by telogen effluvium, diffuse androgenetic alopecia (female-pattern hair loss) and diffuse alopecia areata. Differential diagnosis between the three disorders may be difficult in several occasions. In this second part of our study, chronic telogen effluvium and diffuse alopecia areata are discussed in detail, including clinical, dermoscopic and histological aspects. A flowchart presents a practical and objective differential diagnostic approach to diffuse alopecia.

The objective of the present study was to establish a polymerase chain reaction (PCR) technique for the diagnosis of cutaneous and mucocutaneous leishmaniosis from autochthonous cases in the state of Paraná in southern Brazil as well as imported cases. We sought to determine its utility and accuracy compared with smears and present culture methods. To standardize PCR samples, skin and mucosal punch biopsies from human lesions were performed on patients living in different regions of the Paraná state (76 cases) and other endemic areas of Brazil and Argentina (7 cases). For PCR standardization, two pairs of primers (MP1L/MP3H and B1/B2) were utilized for amplification of the conserved sequences in the minicircle of kinetoplast DNA (kDNA) for the Leishmania braziliensis complex. Two other primer pairs (b1/b2 and a1/a2) were species-specific for L. (V.) braziliensis and L. (V.) amazonensis, respectively. After differential diagnosis, eight patients had clinical diagnosis of the cutaneous ulcer changed to others pathologies such as syphilis, baso-cellular carcinoma, varicose ulcer, ecthyma and paracoccidioidomycosis. Of the 75 patients with cutaneous (CL) and mucocutaneous (MCL) lesions who provided samples, 47 (46 CL + 1 MCL) were diagnosed with leishmaniosis by smear and 57 (52 LC + 5 MCL) were diagnosed by culture methods. In contrast, our PCR technique presented higher accuracy when compared to the direct examination and culture of parasites. PCR is applicable both for CL where all 61 lesions were diagnosed, and MCL where 12 of 14 lesions were diagnosed. This molecular biology technique is also a faster and more specific diagnostic method compared with present parasitological procedures.

Background: Trichotillomania (TM) is a chronic disorder in which patients traumatically remove their own hair in a bizarre pattern. TM histopathological findings are not well defined., Methods: Twenty-eight scalp biopsies of TM were reviewed. Multiple vertical sections and special stains were used to evaluate the specimens. Twenty-six patients (24 female, 2 male) were in the cohort, 2 patients had 2 sets of biopsies., Results: Age range was 13-78 years (mean 41 years), most of them presented with chronic TM. Specific histological findings included trichomalacia (57%) and pigmented casts (46%). Non-specific histological findings included: follicular plugging (96%), decreased number of follicles (96%), reversed anagen:telogen ratio (86%), decreased number of sebaceous glands (68%), melanoderma (68%), increased number of fibrous tracts (64%) and vellus hairs (57%), superficial dermal inflammation (57%), evidence of hemorrhage (18%) and presence of hair granulomas (18%)., Conclusions: Even though TM is often a disease of the young people, middle aged and elderly patients with TM have more often a biopsy to confirm the diagnosis. This paper suggests diagnostic criteria for TM. Specific histological findings and clinical suspicion of TM were considered major criteria, while the non-specific histological findings were considered minor diagnostic criteria for TM.

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum. It manifests by the presence of fever as the only symptom in most individuals. The disease may present as self-limited pneumonia, or as an hematogenous widespread fungal infection with a potentially fatal outcome in elderly individuals and people with compromised T-cell mediated immunity. Here, we report a case of disseminated cutaneous histoplasmosis in a patient with AIDS. The patient was a 33 year old male homosexual, intravenous drug user, who had been diagnosed with HIV infection 5 years earlier. He was in good health, but had erythematous papules and pustules in the skin of the scalp, face, back, thighs, abdomen, palms, and soles. He was placed on anti-retroviral therapy, fluconazole for mucosal candidiasis, trimethoprim/sulfamethoxazole for pneumocystis prophylaxis, and antibiotics for the skin pustules. The skin lesions improved remarkably within 14 days. He was discharged and soon lost to follow-up. After his discharge, skin biopsy and fungal culture results revealed H. capsulatum. He was seen again 1 year later. The interim history revealed that he had taken fluconazole 100 mg/day for 1 month and fluconazole 150 mg/week for 7 months. He had not continued anti-retroviral therapy, nor taken other antifungal drugs. The clinical evolution of the disease was exceptional in that there was disappearance of all the skin lesions attributed to histoplasmosis with fluconazole. Although itraconazole remains the drug of choice for histoplasmosis. Cutaneous histoplasmosis should be considered in the differential diagnosis of atypical cutaneous lesions in individuals infected with HIV.