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Background We previously reported the Alopecia Areata Consensus of Experts study, which presented results of an international expert opinion on treatments for alopecia areata. Objective To report the results of the Alopecia Areata Consensus of Experts international expert opinion on diagnosis and laboratory evaluation for alopecia areata. Methods Fifty hair experts from 5 continents were invited to participate in a 3-round Delphi process. Consensus threshold was set at greater than or equal to 66%. Results Of 148 questions, expert consensus was achieved in 82 (55%). Round 1 consensus was achieved in 10 of 148 questions (7%). Round 2 achieved consensus in 47 of 77 questions (61%). The final face-to-face achieved consensus in 25 of 32 questions (78%). Consensus was greatest for laboratory evaluation (12 of 14 questions [86%]), followed by diagnosis (11 of 14 questions [79%]) of alopecia areata. Overall, etiopathogenesis achieved the least category consensus (31 of 68 questions [46%]). Limitations The study had low representation from Africa, South America, and Asia. Conclusion There is expert consensus on aspects of epidemiology, etiopathogenesis, clinical features, diagnosis, laboratory evaluation, and prognostic indicators of alopecia areata. The study also highlights areas where future clinical research could be directed to address unresolved hypotheses in alopecia areata patient care.

Frontal fibrosing alopecia (FFA) is a recently described inflammatory and scarring type of hair loss affecting almost exclusively women. Despite a dramatic recent increase in incidence the aetiopathogenesis of FFA remains unknown. We undertake genome-wide association studies in females from a UK cohort, comprising 844 cases and 3,760 controls, a Spanish cohort of 172 cases and 385 controls, and perform statistical meta-analysis. We observe genome-wide significant association with FFA at four genomic loci: 2p22.2, 6p21.1, 8q24.22 and 15q2.1. Within the 6p21.1 locus, fine-mapping indicates that the association is driven by the HLA-B*07:02 allele. At 2p22.1, we implicate a putative causal missense variant in CYP1B1, encoding the homonymous xenobiotic- and hormone-processing enzyme. Transcriptomic analysis of affected scalp tissue highlights overrepresentation of transcripts encoding components of innate and adaptive immune response pathways. These findings provide insight into disease pathogenesis and characterise FFA as a genetically predisposed immuno-inflammatory disorder driven by HLA-B*07:02., Frontal fibrosing alopecia (FFA) features lichenoid cutaneous inflammation and scarring hair loss. Here, Tziotzios et al. identify four genetic loci associated with FFA by GWAS followed by Bayesian fine-mapping, co-localisation and HLA imputation which highlights HLA-B*07:02 as a risk factor.

Importance A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata. Objective To generate core domains and domain items for a global network of alopecia areata patient registries. Evidence Review Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019. Findings Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented. Conclusions and Relevance This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.

Context: Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by progressive recession of frontal, and often temporoparietal, hairline mainly in postmenopausal women. Currently, there are no guidelines or proposed evidence-based treatment for FFA. Aims: The aim of this study was to retrospectively evaluate the effect and safety of intralesional triamcinolone acetonide injections (ITAIs) either as monotherapy or as concomitant treatment in the management of hairline recession in FFA. Subjects and Methods: All patients with FFA, who visited our specialist hair clinic from July 2012 to October 2016 and were treated with ITAI either as monotherapy or as concomitant treatment, were enrolled in our study. Measurements were performed from five different points on the scalp. The analysis of data included demographics, associated symptoms, clinical and dermoscopic findings, comorbidities, family history of FFA, concomitant medication, treatment outcome, and recording of adverse events. Statistical Analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences, version 22.0. Results: A total of 40 patients, all females were enrolled in our study. The mean age of the patients was 65.88 ± 8.18 whereas the mean age of the diagnosis was 61.24 ± 7.4. A total of 39 patients were treated with a combination of treatments, including ITAI, and only one with ITAI as monotherapy. There was a halting of the progress of the disease, and no significant adverse events were noted, apart from mild pain. Conclusions: A halting in the progression of FFA was achieved, with unremarkable adverse events. ITAI could serve as an effective and safe option for the treatment of FFA, although difficult to assess it as monotherapy. Further randomized controlled trials are needed to evaluate its efficacy and safety as the sole treatment in the management of FFA.

Summary A 28-year-old man presented with a 10-day history of scalp nodules. He had undergone hair transplantation 2 months previously. Incision and drainage of one of the nodules yielded gelatinous material, which was sent for microscopy and culture, including low-temperature culture. After 2 weeks of incubation, culture of the nodule yielded acid- and alcohol-fast bacilli, which were identified as Mycobacterium abscessus, a rapidly growing, nontuberculous mycobacterium, which has been reported to cause cutaneous, soft tissue and respiratory infections following trauma, surgery or injection with nonsterile needles. A high index of suspicion is therefore needed in patients who present with cutaneous infections after cosmetic dermatological procedures, including hair transplantation.

Dermatologists may see patients with actual or suspected local anaesthetic (LA) allergy who require an urgent dermatological procedure to be performed without time for formal allergy testing. We report a case of shave biopsy and subsequent excision biopsy of an atypical naevus performed using tumescent analgesia with 0.9% saline containing benzyl alcohol preservative. The tumescence itself and the benzyl alcohol present in the 0.9% saline solution provided sufficient analgesia for excision. This technique may be an option for managing urgent procedures in patients suspected or known to have allergy to LA.

Palisaded neutrophilic and granulomatous dermatitis is a rare, cutaneous disease, associated with systemic diseases including rheumatoid arthritis and systemic lupus erythematosus.

Background Advances in telemedicine permit consultations where the doctor and patient are at different sites. Objectives To determine whether this technology could be used to triage referrals of pigmented lesions to a dermatology out-patient clinic, and thereby assist in managing the ever increasing number of lesions being referred. Methods When patients attended clinic, a clinical diagnosis of their pigmented lesion was made and recorded. A still image of each lesion was subsequently taken from a video camera using a PC card, and stored. These images were subsequently viewed in conjunction with the general practitioner's referral information and designated as ‘warrants referral’ or ‘does not warrant referral’. For each lesion this decision was compared with the clinical diagnosis made during the live consultation in the clinic (the ‘gold standard’). Clinical diagnoses designated as warranting referral were malignant melanoma, basal cell carcinoma, keratoacanthoma, atypical naevus and pyogenic granuloma (due to the potential clinical confusion with amelanotic melanoma). Lesions that were not considered to warrant referral included benign melanocytic naevus, seborrhoeic keratosis, dermatofibroma, congenital naevus, solar lentigo, actinic keratosis and various other benign conditions. Results In total, 819 lesions were evaluated, resulting in a mean sensitivity of 81% and specificity of 73% for the technique. Conclusions We feel that the overall sensitivity of 81% is encouraging as regards the use of such a technique as a triage tool, but that the inability to examine the whole patient or palpate the lesions is a major drawback in the safe triage of patients with pigmented lesions.

Rapid expansion of communication technology has permitted the clinician to perform a consultation with a patient located at a different site. Assuming adequate diagnostic accuracy, it could theoretically be possible to use telemedical techniques as a triage tool. Images of pigmented lesions sent by the primary care physician could be viewed by the consultant dermatologist, and those with banal lesions spared from attending clinic. Previous studies assessing diagnostic accuracy of images of lesions have used ‘face-to-face’ diagnoses as the ‘gold standard’. We set out to compare diagnostic accuracy of image examination compared with that of clinical examination, using histological examination as the diagnostic benchmark. We found that pigmented lesions may be diagnosed as accurately by stored video image evaluation as by conventional clinical examination. None of the malignant skin tumours was misdiagnosed as benign in either group. Whilst these results are encouraging in terms of the clinical safety of store-and-forward imaging, the inability to examine the whole patient or to palpate the lesions may limit the acceptability of the technique severely. Further evaluation of the cost : benefit ratio of such a system to the health care provider must be undertaken before considering this technique as a potential adjunct to managing outpatient referrals.

A 10-month-old child presented with an ulcerated lesion on his right arm. The lesion was caused by arginine monohydrochloride extravasation during growth hormone testing, performed 2 months before. On physical examination, there was a 3 cm x 4 cm oval sore, with a thick fibrous base and turgid, violaceous, raised edges on the dorsal aspect of the child's right hand and wrist. Conservative management with local medications led to complete resolution within 2 months.

A 26 year old rider presented with a six year history of recurrent subcutaneous lumps on her thighs during winter.⇑ Examination …

We report a large family with ichthyosis bullosa of Siemens (IBS) including eight affected members spanning three generations. The classical features of the disease were consistently observed with blistering, superficial peeling of the skin, and localized lichenified hyperkeratosis mainly confined to the limbs. Phenotypic variation, however, was also observed with some individuals exhibiting unusual clinical features. Specifically, the index patient was erythrodermic at birth; she subsequently developed a widespread pustular eruption. Erythroderma is classically absent in IBS and pustulation is very unusual. She also had hypertrichosis of the limbs, as did an affected female first cousin. This has not previously been reported in IBS. Electron microscopy showed complex aggregates of keratin in the spinous and granular layers associated, in places, with remarkably little cell lysis. Sequencing of genomic DNA revealed a mutation (E493K) in keratin 2e. A review of the literature on IBS indicates that E493K is the most commonly reported mutation to date and might represent a mutational hotspot for this disease.