Characteristics and Clinical Manifestations of Pigmented Purpuric Dermatosis

Background

Pigmented purpuric dermatoses (PPD) are a spectrum of disorders characterized by a distinct purpuric rash. Although PPD can be easily diagnosed, the disease entity remains an enigma and a therapeutic challenge.

Objective

The purpose of this study was to investigate the characteristics and clinical manifestations of PPD and to elucidate the relationship between assumed etiologic factors and the clinical manifestations of PPD and treatment responses.

Methods

Retrograde analyses were performed to identify appropriate PPD patients who visited Korea University Medical Center Anam Hospital from 2002 to 2012.

Results

Information on 113 patients with PPD was analyzed, and 38 subjects with skin biopsy were included for this study. Schamberg''s disease was the most frequent clinical type (60.5%). Concomitant diseases included hypertension (15.8%), diabetes (10.5%), and others. Associated medication histories included statins (13.2%), beta blockers (10.5%), and others. Possibly associated etiologic factors were recent upper respiratory infection (5.3%), high orthostatic pressure due to prolonged standing (2.6%), and strenuous exercise (2.6%). A total of 36 patients (94.7%) were treated with one or more treatment methods, including oral antihistamines, pentoxifylline, topical steroids, and/or phototherapy. There was no significant difference in disease progress according to underlying diseases, medications, or association factors (p>0.05).

Conclusion

Our overall results were grossly consistent with the existing literature, excluding several findings. Although a possible relationship between PPD and cardiovascular disease or cardiovascular medication was proposed at the beginning of the study, no statistically significant correlations were found according to the specific clinical types and treatment responses (p>0.05).     

Clinical Characteristics of Cholinergic Urticaria in Korea

Background

Cholinergic urticaria is a type of physical urticaria characterized by heat-associated wheals. Several reports are available about cholinergic urticaria; however, the clinical manifestations and pathogenesis are incompletely understood.

Objective

The purpose of this study was to investigate the clinical characteristics of cholinergic urticaria in Korea.

Methods

We performed a retrospective study of 92 patients with cholinergic urticaria who were contacted by phone and whose diagnoses were confirmed by the exercise provocation test among those who had visited The Catholic University of Korea, Catholic Medical Center from January 2001 to November 2010.

Results

All 92 patients were male, and their average age was 27.8 years (range, 17~51 years). Most of the patients had onset of the disease in their 20s and 30s. Non-follicular wheals were located on the trunk and upper extremities of many patients, and the symptoms were aggravated by exercise. Eight patients showed general urticaria symptoms and 15 had accompanying atopic disease. Forty-three patients complained of seasonal aggravation. Most patients were treated with first and second-generation antihistamines.

Conclusion

Dermatologists should consider these characteristics in patients with cholinergic urticaria. Further investigation and follow-up studies are necessary to better understand the epidemiological and clinical findings of cholinergic urticaria.     

Observational descriptive study of cutaneous manifestations in patients from Mato Grosso with viral chronic hepatitis

BACKGROUND

Extrahepatic manifestations are seen in association with chronic infection by hepatitis B or C virus including cutaneous disorders. The frequency of these findings seems to vary among different places and reports. There is a lack of information about this issue in Brazil.

OBJECTIVES

To estimate the prevalence of cutaneous findings affecting HBV or HCV carriers from a reference outpatient unit in Mato Grosso.

METHODS

A cross-sectional observational study.

RESULTS

108 patients were studied. 88.9% presented some cutaneous findings but must of them were nonrelated to chronic viral infection. Four patients had cutaneous or autoimmune syndromes that may be HBV or HCV related.

CONCLUSION

In our study we found no statistical association between viral hepatitis and skin diseases.     

Clinical Features of Systemic Contact Dermatitis Due to the Ingestion of Lacquer in the Province of Chungcheongnam-do

Background

Lacquer contains an allergen, which can cause severe contact dermatitis. Systemic dermatitis resulting from the ingestion of lacquer is quite common in Korea, until now.

Objective

The purpose of this study is to elucidate the clinical features and laboratory findings of systemic contact dermatitis (SCD), due to the ingestion of lacquer in Chungcheongnam-do.

Methods

We retrospectively reviewed the medical records of 33 patients with SCD, after ingestion of lacquer from Soonchunhyang University Hospital in Cheonan, over a 6-month period.

Results

In this study, 33.3% of patients ate lacquer, as a health food, and some (15.2%) by encouragement of friends or spouse. The most common way of ingestion was the lacquer-boiled chicken (48.5%), but many also ate lacquer tree sprouts (42.4%). The skin lesions developed as erythematous maculopapular eruptions, erythema multiforme, erythroderma, purpura, wheals and vesicles. On laboratory findings, 13 patients (52%) exhibited leukocytosis and 11 patients had elevated eosinophil counts.

Conclusion

The general public is becoming more aware of the toxic effects of lacquer ingestion, but still does not fully understand the dangers of lacquer tree sprouts, and this ignorance is frequently causing SCD in Chungcheongnam-do.     

Analysis of MAST-CLA Results as a Diagnostic Tool in Allergic Skin Diseases

Background

Urticaria and atopic dermatitis are representative allergic skin diseases that can be mediated by IgE. Measuring levels of specific IgE can be used to confirm causative agents of these skin diseases.

Objective

To analyze results from the multiple allergosorbent test chemiluminescent assay (MAST-CLA), which measures specific IgE in the presence of a causative agent/allergen, in IgE-mediated skin diseases.

Methods

A total of 404 patients with urticaria, atopic dermatitis or pruritus were enrolled in the present study. Positive rates of specific IgE as well as total serum IgE from the MAST-CLA were compared.

Results

Positive rates of specific IgE were highest in atopic dermatitis patients, followed by urticaria, and then pruritus, with 57.0%, 37.1%, and 20.8%, respectively (p<0.05). House dust mite species were the most common allergens in both atopic dermatitis and urticaria skin diseases. There were no differences in the overall MAST-CLA results between acute and chronic urticaria. The relative positive rate of inhalant allergen was significantly higher in adult than in child atopic dermatitis patients.

Conclusion

Results from the MAST-CLA showed diversity among the three disease groups, and within each disease group, with different positive rates of specific IgE, a different mean allergen number per patient, and so on. Therefore, we concluded that MAST-CLA could be a useful diagnostic tool for various allergic skin diseases.     

Patch test results in children and adolescents. Study from the Santa Casa de Belo Horizonte Dermatology Clinic,Brazil, from 2003 to 2010

BACKGROUND

Patch testing is an efficient method to identify the allergen responsible for allergic contact dermatitis.

OBJECTIVE

To evaluate the results of patch tests in children and adolescents comparing these two age groups'' results.

METHODS

Cross-sectional study to assess patch test results of 125 children and adolescents aged 1-19 years, with suspected allergic contact dermatitis, in a dermatology clinic in Brazil. Two Brazilian standardized series were used.

RESULTS

Seventy four (59.2%) patients had "at least one positive reaction" to the patch test. Among these positive tests, 77.0% were deemed relevant. The most frequent allergens were nickel (36.8%), thimerosal (18.4%), tosylamide formaldehyde resin (6.8%), neomycin (6.4%), cobalt (4.0%) and fragrance mix I (4.0%). The most frequent positive tests came from adolescents (p=0.0014) and females (p=0.0002). There was no relevant statistical difference concerning contact sensitizations among patients with or without atopic history. However, there were significant differences regarding sensitization to nickel (p=0.029) and thimerosal (p=0.042) between the two age groups under study, while adolescents were the most affected.

CONCLUSION

Nickel and fragrances were the only positive (and relevant) allergens in children. Nickel and tosylamide formaldehyde resin were the most frequent and relevant allergens among adolescents.     

Eccrine Angiomatous Hamartoma: A Review of Ten Cases

Background

Eccrine angiomatous hamartoma (EAH) is a rare benign nodular lesion characterized by the proliferation of eccrine and vascular structures, generally capillaries, in the middle and deep dermis. It may be congenital or appear later in childhood, but rarely arises in adulthood.

Objective

To investigate the clinicopathologic features of EAH in Korean patients.

Methods

Ten cases of EAH diagnosed at Ajou University Hospital and Gangnam Severance Hospital in Korea from 2007 to 2010 were retrospectively reviewed.

Results

The age range of patients was between 5 and 66 years with an equal number of male and female patients. Apart from two congenital cases, the onset was late, ranging from 6 months to 65 years of age. All lesions were solitary and located on the distal extremities. Nine cases appeared as a yellow-brown nodule or plaque resembling a callus. Neither hyperhidrosis nor hypertrichosis was documented. Apart from the typical histological findings of EAH, prominent mucin deposition, fat component and nerve infiltration were observed.

Conclusion

This is one of the largest single case series of EAH in the literature. Clinically, resemblance to callosities and the frequent occurrence in the adulthood were the unique features in our series.     

The Fine Scratches of the Spectacle Frames and the Allergic Contact Dermatitis

Background

Spectacle contact allergy is not infrequent. The fine scratches on the spectacle frames which may play a role in the sensitization to the potential allergenic components have not been studied.

Objective

We sought the relationship between the scratches on the spectacle frames and the allergic contact dermatitis (ACD) in the Republic of Korea.

Methods

A total of 42 Korean patients with ACD at the spectacle contact sites were enrolled. Their spectacle frames were examined with the dimethylglyoxime (DMG) test and analyzed by the scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). Patch tests (thin-layer rapid use epicutaneous test [TRUE tests]) were performed to identify the skin allergens.

Results

The DMG-positive spectacle frames were identified in 78.5% of the frames. The SEM results showed that there were more scratches on the skin-contacting parts of the spectacle frames than the non-skin-contacting parts of the same frames. In the EDS findings, the mean nickel content (weight, %) of the spectacle frames was 15.7±5.5, and the mean chromium content was 20.3±3.4 at the skin-contacting parts. In the TRUE tests, nickel sulphate was the most common allergen (31 cases, 73.8%), and potassium dichromate was the second (9 cases, 21.4%). Three patients presented simultaneous positive reactions with nickel sulphate and potassium dichromate.

Conclusion

Minor visible and non-visible fine scratches on the spectacle frames may present the provocation factors of the ACD. Nickel sulphate was the most common allergen suspected of provoking the spectacle frame-induced ACD, followed by potassium dichromate.     

Differences in Comorbidity Profiles between Early-Onset and Late-Onset Alopecia Areata Patients: A Retrospective Study of 871 Korean Patients

Background

Alopecia areata (AA) is a common dermatologic condition with a broad spectrum of clinical features and age of onset, classically characterized by nonscarring patches of hair loss. In the past, early-onset (before adolescence) AA has been associated with various autoimmune diseases, especially atopic diseases and lupus erythematosus and demonstrates a worse prognosis compared with late onset AA.

Objective

To evaluate the differences in the comorbidity profile of AA with regard to age at onset.

Methods

We completed a retrospective study of 871 Korean AA patients seen at our department within the last 10 years. After these patients were subdivided according to onset before or after age 13 years, the two groups were compared on the basis of their comorbid disorders, family history of AA, and hematologic test results.

Results

Our results demonstrate that significantly more patients in the early-onset group had a personal history of atopic dermatitis or family history of AA. These findings are consistent with previous reports associating early-onset AA with autoimmune diseases and a family history of AA in different ethnic populations. Most of the serologic test values showed no significant differences between the groups and the results were considerably affected by age.

Conclusion

This study is significant because it is a large group study in Korean AA patients, and Korean AA patients with an onset age before adolescence show similar clinical manifestations to other ethnic populations.     

Lack of Association between PTPN22 Gene +1858 C>T Polymorphism and Susceptibility to Generalized Vitiligo in a Turkish Population

Background

Vitiligo is an autoimmune polygenic disorder characterized by loss of pigmentation due to melanocyte destruction. The PTPN22 gene +1858 C>T single nucleotide polymorphism (rs2476601) has been shown to be associated with various autoimmune disorders.

Objective

The aim of this study was to investigate whether the PTPN22 gene +1858 C>T single nucleotide polymorphism is associated with susceptibility to generalized vitiligo in a Turkish population.

Methods

One hundred and seven patients with generalized vitiligo, and one hundred and twelve gender-, age-, and ethnic-matched controls were enrolled in the study. Genotyping was done by polymerase chain reaction-restriction fragment length polymorphism.

Results

The PTPN22 +1858 C>T genotype and allele frequencies of the generalized vitiligo patients did not differ significantly from those of healthy controls.

Conclusion

We found no association between the PTPN22 +1858 C>T gene polymorphism and vitiligo susceptibility in Turkish generalized-vitiligo patients.     

Comorbidities and cardiovascular risk factors in patients with psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease and its pathogenesis involves an interaction between genetic, environmental, and immunological factors. Recent studies have suggested that the chronic inflammatory nature of psoriasis may predispose to an association with other inflammatory diseases, especially cardiovascular diseases and metabolic disorders.

OBJECTIVES

To describe the demographic, clinical, epidemiological, and laboratory characteristics of a sample of psoriasis patients; to assess the prevalence of cardiovascular comorbidities in this group of patients; and to identify the cardiovascular risk profile using the Framingham risk score.

METHODS

We conducted a cross-sectional study involving the assessment of 190 patients. Participants underwent history and physical examination. They also completed a specific questionnaire about epidemiological data, past medical history, and comorbidities. The cardiovascular risk profile was calculated using the Framingham risk score.

RESULTS

Patients'' mean age was 51.5 ± 14 years, and the predominant clinical presentation was plaque psoriasis (78.4%). We found an increased prevalence of systemic hypertension, type 2 diabetes, metabolic syndrome, and obesity. Increased waist circumference was also found in addition to a considerable prevalence of depression, smoking, and regular alcohol intake. Patients'' cardiovascular risk was high according to the Framingham risk score, and 47.2% of patients had moderate or high risk of fatal and non-fatal coronary events in 10 years.

CONCLUSIONS

Patients had high prevalence of cardiovascular comorbidities, and high cardiovascular risk according to the Framingham risk score. Further epidemiological studies are needed in Brazil for validation of our results.     

Research of primary hyperhidrosis in students of medicine of the State of Sergipe,Brazil

BACKGROUND

Hyperhidrosis or excessive sweat production occurs at 2.9-9% of the population.

OBJECTIVE

To estimate the prevalence and disorders due to primary hyperhidrosis (HP) in medicine students in the state of Sergipe.

METHODS

Cross-sectional study using individual interviews.

RESULTS

Hyperhidrosis was found in 14.76% of subjects, the most affected regions were palmar, plantar and axillary, causing prejudice in daily activities. Family history occurred in 45% and 22.72% was diagnosed by a physician.

CONCLUSION

The prevalence of hyperhidrosis in medicine students of Sergipe was high, with strong family and a small portion of diagnoses made by medical professionals.     

Personality Traits and Common Psychiatric Conditions in Adult Patients with Acne Vulgaris

Background

We believe that instances of neuroticism and common psychiatric disorders are higher in adults with acne vulgaris than the normal population.

Objective

Instances of acne in adults have been increasing in frequency in recent years. The aim of this study was to investigate personality traits and common psychiatric conditions in patients with adult acne vulgaris.

Methods

Patients who visited the dermatology outpatient clinic at Bozok University Medical School with a complaint of acne and who volunteered for this study were included. The Symptom Checklist 90-Revised (SCL 90-R) Global Symptom Index (GSI), somatization, depression, and anxiety subscales and the Eysenck Personality Questionnaire-Revised Short Form (EPQ-RSF) were administered to 40 patients who fulfilled the inclusion criteria before treatment. The results were compared with those of a control group.

Results

Of the 40 patients included in this study, 34 were female and 6 were male. The GSI and the somatization, depression, and anxiety subscales of the SCL 90-R were evaluated. Patients with adult acne had statistically significant higher scores than the control group on all of these subscales. In addition, patients with adult acne had statistically significantly higher scores on the neuroticism subscale of the EPQ-RSF.

Conclusion

Our results show that common psychiatric conditions are frequent in adult patients with acne. More importantly, neurotic personality characteristics are observed more frequently in these patients. These findings suggest that acne in adults is a disorder that has both medical and psychosomatic characteristics and requires a multi-disciplinary approach.     

Notch Intracellular Domain Expression in Various Skin Fibroproliferative Diseases

Background

The effects of the Notch signaling pathway in fibroproliferative skin diseases have not been fully elucidated.

Objective

The aim of this study was to investigate the expression of activated Notch signaling molecules in various skin fibroproliferative diseases.

Methods

Immunohistochemical analysis of Notch intracellular domain (NICD) expression in keloid, hypertrophic scar, morphea, dermatofibroma, and normal control skin specimens was performed, and the clinical characteristics of patients with various skin fibroproliferative diseases were analyzed.

Results

NICD was highly expressed in fibroblasts of keloids and moderately to highly expressed in hypertrophic scars and dermatofibromas, whereas low or no expression was detected in the fibroblasts of normal skin specimens and morpheas. NICD was constitutively expressed in keratinocytes, endothelial cells, and immune cells in normal skin specimens.

Conclusion

NICD was significantly expressed in human fibroproliferative skin disorders, especially keloids, suggesting that an activated Notch signaling pathway is involved in the pathogenesis of skin fibrosis.     

Total Serum Oxidant/Antioxidant Status and Arylesterase Activity in Recurrent Aphthous Stomatitis

Background

Recurrent aphthous stomatitis (RAS) is a chronic relapsing inflammatory disorder of the oral mucosa with unknown etiology. Oxidative stress (OS) is suggested to play a main role in the etiopathogenesis in RAS.

Objective

In this study, we hypothesize that a systemic OS is present in patients with RAS.

Methods

Forty-four patients with active RAS lesions and 38 healthy controls were being included in the study. Serum total oxidant status (TOS), total antioxidant status (TAS), oxidative stress index (OSI), and paraoxonase 1 arylesterase (ARES) activity were being determined.

Results

RAS patients had significantly lower TAS levels and higher TOS and OSI values than controls. The patients had a lower ARES activity when compared to healthy controls. No correlations were observed between OS parameters and age, gender, duration of disease or frequency of RAS attacks per month.

Conclusion

A systemic OS is determined with an imbalance in oxidant/antioxidant status and lower ARES activity in RAS. Systemic OS may have an important role in the pathogenesis of RAS formation.     

Vitamin D Status and Its Association with the SCORAD Score and Serum LL-37 Level in Korean Adults and Children with Atopic Dermatitis

Background

Vitamin D insufficiency could be associated with the prevalence of atopic dermatitis (AD).

Objective

To examine vitamin D status and the relations between serum 25-hydroxyvitamin D levels, SCORAD score, serum LL-37 level, and body mass index (BMI) in Korean AD patients, and to explore whether these associations differ between adults and children.

Methods

Serum 25-hydroxyvitamin D levels, serum LL-37, and clinical features were analyzed in a total of 72 Korean patients with AD (39 adults and 33 children) and 140 healthy control subjects (70 adults and 70 children).

Results

Serum 25-hydroxyvitamin D levels were significantly reduced in children with AD (15.06±4.64 ng/ml) compared with normal children in the control group (16.25±6.60 ng/ml) (p=0.036). Significant inverse correlations were found between BMI and 25-hydroxyvitamin D level (r=-0.315, p=0.007) and between the SCORAD score and serum LL-37 level (r=-0.3, p=0.011) in the total AD patients.

Conclusion

The results showed that serum vitamin D levels were lower in children with AD than in healthy children; however, the same relation was not observed between adults with AD and healthy adults. Serum 25-hydroxyvitamin D concentration was not significantly correlated with AD severity or serum LL-37 levels in our study population.     

Different Anatomical Distribution of Basal Cell Carcinoma Subtypes in Iranian Population: Association between Site and Subtype

Background

Basal cell carcinoma (BCC) is the most common type of human cancer. Despite the high prevalence of these tumors, there is a lack of reliable epidemiological data in some regions including Iran.

Objective

To assess the relationship between BCC subtypes and anatomical distribution in the Iranian population.

Methods

There were 876 patients with a single BCC enrolled in this study (March 2007 to March 2010; Razi Dermatology Center, Tehran, Iran).

Results

Among 876 patients, 544 were males and 332 females. Of the lesions, 43% were nodular, 32.4% mixed type, 3% superficial and rest of other subtypes. In the lesion location, 58.2% were on the face, 29.2% on scalp, 6.2% on ears, 2.3% on neck, 1.7% on trunk and 1.3% on the extremities. There was no significant difference between male and female in the BCC subtypes, but anatomical distribution of the tumor was different (p=0.002). Most of the trunk-arising BCCs were superficial, and most of the facial BCCs were nodular subtype. Also, most of the BCC subtypes occurred in patients between 40 to 80 years old and mostly on the face and scalp (p=0.04). However, superficial BCCs mostly occurred in younger patients over others (p=0.001).

Conclusion

Subtype is associated with a site, independent of gender or age. Also BCCs occurring on the trunk are mostly of the superficial subtype.     

A Clinicopathologic Study of Thirty Cases of Acquired Perforating Dermatosis in Korea

Background

Acquired perforating dermatosis (APD) is histopathologically characterized by transepidermal elimination of materials from the upper dermis. APD can be divided into four diseases: Kyrle''s disease, perforating folliculitis, elastosis perforans serpiginosa, and reactive perforating collagenosis. APD is usually associated with systemic diseases, especially diabetes mellitus or chronic renal failure. So far, there have only been a few Korean studies of APD, which have a limited number of patients.

Objective

The aim of this study is to evaluate the clinical and histopathologic characteristics of 30 cases of APD and to examine the association with systemic diseases.

Methods

We retrospectively reviewed the medical records and biopsy specimens of 30 patients who were diagnosed with APD.

Results

The mean age was 55.5 years, and the average duration of the lesion was 7.8 months. The lower extremities (73.3%) were the most frequently occurring sites of the lesion. Twenty-five patients (83.3%) had pruritus, and Koebner''s phenomenon was present in 11 patients. Patients of 63.3% had at least one systemic disease. Diabetes mellitus (n=17, 56.7%) and chronic renal failure (n=10, 33.3%) were the most commonly associated conditions. Most patients received topical steroids (93.3%) and antihistamines (80.0%). The most common histopathologic type was reactive perforating collagenosis (n=23, 73.3%).

Conclusion

In this study, most patients had a systemic association to the diseases. Therefore, we suggest that further evaluation is necessary for patients who present with APD. This includes reviewing patient''s comprehensive past medical history, clinical exam, and additional diagnostic testing to check for the possibility of associated systemic diseases.     

Evaluating the effectiveness of the customized Unna boot when treating patients with venous ulcers

BACKGROUND

Lower limb ulcers are a serious medical and socioeconomic problem throughout the world. One type of chronic wound of the lower extremities is the venous ulcer. Therapeutic methods for treating venous ulcer include the use of the Unna boot.

OBJECTIVES

To evaluate the effectiveness of the customized Unna boot in the treatment of venous ulcers and to monitor the subsequent development and healing of the lesions.

METHODS

Prospective exploratory and quantitative longitudinal study, conducted at the "Outpatients Department (Wound Care) of the Grupo da Fraternidade Espírita Irmão Alexandre" in the city of Pouso Alegre (MG), Brazil, in 2008. The sample consisted of 32 patients with venous ulcers who underwent treatment with the Unna boot and 11 patients (control group), who used a simple bandage application. The patients''lesions were monitored over a three month period.

RESULTS

The average age of the predominently female (65.1%) patients was 61.88. From observing the differences in healing times at the three evaluation stages, it was clear that after the initial evaluation the wound area decreased in Groups 1 and 2 (p>0.05).

CONCLUSION

The use of the customized Unna boot contributes to quicker healing. However, over a period of three months the simple bandage applications were seen to be just as effective as the Unna boot method.     

The Influence of Pregnancy and Menstruation on the Deterioration of Atopic Dermatitis Symptoms

Background

Female patients with atopic dermatitis (AD) often experience cutaneous deterioration associated with their pregnancy or menstrual cycle.

Objective

We wanted to determine the prevalence of symptom aggravation as related to pregnancy and the menstrual cycle in female patients with AD.

Methods

One hundred female patients with AD were included in the study and interviews were performed. The total IgE level and the Eczema Area and Severity Index score of the patients were retrospectively reviewed.

Results

Ninety seven patients replied the questionnaire, and among them, 23 patients had completed at least 1 pregnancy. Among the 23 women who experienced pregnancy, 14 (61%) had noticed deterioration of their clinical symptoms during pregnancy. Of the 97 females, 31 (32%) patients had noticed deterioration of their AD as related to their menstrual cycle. For the patients who were sub-grouped as the intrinsic type of AD, the prevalence of symptom aggravation as related to pregnancy was significantly higher as compared to that of the extrinsic type of AD patients (p=0.048).

Conclusion

Of the 97 patients, 45 (46%) females answered that they have experienced deterioration of AD during pregnancy or in relation to their menstrual cycle, and this suggests the relation of a hormonal influence on the clinical manifestations of AD.