Dermoscopy in vitiligo: diagnosis and beyond

Background

Vitiligo is essentially a clinical diagnosis, and dermoscopy may aid in noninvasive confirmation of diagnosis by excluding other clinically simulating hypopigmentary conditions. More importantly, dermoscopy is rapidly gaining ground as an important adjunct tool to evaluate disease activity.

Aim

To study the dermoscopic features of vitiligo and ascertain their correlation with disease activity.

Methods

Retrospective analysis of dermoscopy of 60 cases suffering from vitiligo was undertaken. Dermoscopy was performed using Dermlite II hybrid m dermatoscope at 10× magnification in polarized mode, and photographs were captured by Apple iphone 6. Variables assessed in the dermoscopic evaluation included perifollicular changes, perilesional changes, altered pigmentary network, and presence of specific features such as the starburst appearance, comet tail appearance, leukotrichia, telangiectasia, and any new findings.

Results

Sixty patients with stable, progressive, or repigmenting vitiligo were retrospectively studied. While perifollicular depigmentation (PFD) was predictive of stable vitiligo, perifollicular pigmentation (PFP) was characteristic of active disease. Starburst appearance, altered pigment network, and comet tail appearance, were also noted, and these were typical of progressive vitiligo. A new dermoscopic feature, the ‘tapioca sago’ appearance (sabudana), was observed in the skin adjacent to the vitiligo lesion only in patients with progressive vitiligo .

Conclusion

Dermoscopy is useful in assessing the stage of evolution and the status of disease activity in vitiligo. The most useful dermoscopic clues are observed in the perifollicular region, since progressive lesions display perifollicular pigmentation and stable/remitting lesions display perifolliclar depigmentation.     

Adrenoceptor-mediated modulation of evans blue dye permeation of rat small intestine

In the present study, we addressed the problem whether sympathoadrenal mechanisms could influence the paracellular permeation of macromolecules from the lumen to the lamina propria of the small intestine. Experiments were conducted with rats that were anesthetized with ether for 10–20 min, during which time laparotomy was performed and six consecutive loops (each of 5 cm length) of the jejunum were prepared. A 3% solution of the azo dye, Evans blue (EB; MW 960.83) in phosphate-buffered saline,was instilled into each loop at a volume of 0.3 ml, this compound serving as a marker for tight junctional permeability. Thereafter, the abdomen was closed and the rats were allowed to wake up, but were killed after 60 min. The loops were dissected, opened, and rinsed with acetylcysteine in order to remove the adherent mucus layer. Each loop was weighed and incubated with formamide for 24 hr to elute the amount of EB absorbed, which was quantitated spectrophotometrically. In the control situation, the uptake was homogenous along the loops. -Adrenoceptor-blocking, or-stimulating agents could influence the uptake considerably. The data obtained could indicate that noradrenergic nerves, via an activation of ₂-adrenoceptors, may cause an increase of tight junction permeability for macromolecules, but circulatory mechanisms also must be taken into account in order to explain the observed effects.The study was supported by the Swedish Farmers Foundation for Agriecltural Research (project no. 922903). Ismelin was a kind gift from Ciba-Geigy AB, Västra Frölunda, Sweden.     

Problems encountered in setting up support groups in nursing

There has been much discussion on the value of support groups as a means of enabling nurses to deal with the emotional costs of their daily work. This paper describes a range of problems encountered while setting up support groups. Some of the groups were specifically to help nurses give up smoking while others were planned to help with a wide range of problems. From the findings, suggestions are made which may be of value to nurses in all specialties.     

Management of the oral manifestations of senile purpura in an edentulous patient: a case report

Senile purpura occurs because of a weakness of the vascular supporting tissues mainly caused by aging and is most often seen on the dorsal surface of the hands and the extensor surfaces of the forearms, and has also been observed in the oral mucosa of elderly patients. These red lesions present as sharply margined subcutaneous hemorrhagic spots and are due to trauma, such as damage to the endothelium of small blood vessels, or a coagulation defect. They can also be due to reduced perivascular support, or capillary fragility and permeability, or a combination of all of these factors. Oral manifestation of senile purpura can also be induced by long periods of medication use leading to fragile areas of the mucosa. The presence of senile purpura requires continuous follow‐up since drug‐induced purpura may cause plaque function alterations. An accurate diagnosis in elderly complete denture wearers can minimize bleeding and prevent possible development of ulcerations under the dentures, especially during the adaptation period to the prosthesis. This case report, presents the care and 3‐year follow‐up of a 66‐year‐old woman with complete dentures who presented with the oral manifestations of senile purpura caused by the continued use of several medications.     

Effects of pulse methylprednisolone on inflammatory mediators in peripheral blood,synovial fluid,and synovial membrane in rheumatoid arthritis

Objective. To establish whether the clinical efficacy of pulse methylprednisolone (MP; 1,000 mg intravenously) is related to the modulation of proinflammatory cytokines within the peripheral blood, synovial membrane, or synovial fluid compartments. Methods. Eighteen patients with active rheumatoid arthritis (RA) were studied. Peripheral blood (11 patients) and knee synovial fluid (9 patients, 10 knees) were obtained before and at 4 and 24 hours after MP therapy. Interleukin-1β (IL-1β), IL-8, and tumor necrosis factor α (TNFα) were measured by enzyme-linked immunosorbent assay and biologic assays; prostaglandin E₂ (PGE₂) was measured by competitive radioimmunoassay. In 10 patients, arthroscopically directed synovial biopsies were obtained before and at 24 hours after treatment, at disease relapse (4 patients), and after retreatment (1 patient). Membranes were stained by immunohistochemical techniques with monoclonal antibodies against TNFα, IL-8, IL-1β, and the IL-1 receptor antagonist protein (IL-1Ra). Results. MP therapy was associated with a rapid (within 24 hours) and substantial decrease in the expression of TNFα in the lining and sublining regions of the synovial membrane, as well as substantial decreases in the levels of TNFα in serum and synovial fluid. There was also reduced IL-8 expression in the synovial lining, as well as reduced synovial fluid IL-8 levels. No effect on synovial membrane IL-1β and IL-1Ra or synovial fluid IL-1β and PGE₂ was found. Conclusion. MP therapy rapidly reduces IL-8 and TNFα levels in the synovial compartment, with cytokine changes in the serum and synovial fluid reflecting the changes in the synovial membrane. Alterations in TNFα expression in the synovial membrane correlated with clinical response to, and subsequent relapse after, MP therapy.     

Adenosine A1 receptor promotion of multinucleated giant cell formation by human monocytes. A mechanism for methotrexate-induced nodulosis in rheumatoid arthritis

Objective. To determine why methotrexate (MTX) exacerbates rheumatoid nodules in some patients, despite the effective suppression of synovial inflammation. Methods. Phorbol myristate acetate (PMA)-induced differentiation of monocytes into multinucleated giant cells was used as an in vitro model to study the effects of adenosine on nodulosis. Results. MTX at 200-2,000 nM or the adenosine A₁ agonist N⁵-cyclopentyl adenosine (CPA) (10⁻¹² to 10^-9 M) or the A₂ antagonist 3,7-dimethyl-1-propargylxanthine markedly enhanced giant cell formation, whereas the adenosine A₁ antagonist 8-cyclopentyl-dipropylxanthine completely reversed these effects. PMA, CPA, and MTX induced adenosine release by cultured monocytes at concentrations consistent with those associated with predominantly A₁ effects. Furthermore, surface expression of A₁ receptors was found to remain unchanged on the differentiating cells throughout the culture period. Conclusion. Agents that inhibit adenosine A₁ receptors might be useful in the treatment of MTX-induced rheumatoid nodulosis, while still potentiating the A₂-mediated antiinflammatory effects of MTX on synovitis.     

The AIMS2-SF. A short form of the arthritis impact measurement scales 2

Objective. To develop a short form of the Arthritis Impact Measurement Scales 2 (AIMS2) questionnaire, preserving content validity as the priority criterion. Methods. A 2-step reduction procedure was used: 1) Delphi technique, with 1 panel of patients and 1 panel of experts each selecting 1 set of items independently; and 2) nominal group technique, where members of both panels reached consensus on the final selection of items, using information derived from item analysis. Psychometric properties of the AIMS2-Short Form (AIMS2-SF) and AIMS2 were compared using data from a cohort of 127 rheumatoid arthritis patients who completed the AIMS2 twice prior to the initiation of methotrexate (MTX) treatment and 3 months post-initiation of MTX treatment. Results. The 2 panels reached consensus on a 26-item AIMS2-SF (54.4% reduction from the AIMS2). Factor analysis showed preservation of the 5-component structure. Convergent validity (Physical and Symptom components with clinical variables: r = 0.24-0.59), test-retest reproducibility (intraclass correlation coefficient >0.7), and sensitivity to change at 3 months (standardized response mean 0.36-0.8, except Social Interaction component [0.08]) were very close to the values for the original AIMS2. Conclusion. The AIMS2-SF is a shorter version of the AIMS2 (i.e., available in 2-page format) and has psychometric properties similar to those of the AIMS2.