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SYSTEMIC INVOLVEMENT IN CUTANEOUSSARCOIDOSIS

Cutaneous involvement is found in 25% of cases of sarcoid,but most studies of cutaneous sarcoidosis have been drawnfrom populations with already defined pulmonary disease.

In this study, patients presenting with a histological diag-nosis of non-caseating sarcoidal granuloma on skin biopsyover a 10-year period were reviewed. Of the 34 patients, 21were found to have extracutaneous systemic sarcoid. Allpatients with lupus pernio and ulcerated sarcoidal skinlesions had extracutaneous disease. Neither the extent northe presence of papular lesions were found to be associatedwith systemic involvement, unlike some previous studies.The authors conclude that all patients presenting with cuta-neous sarcoidal granulomas require investigation for sys-temic sarcoid, but approximately 30% will have diseaselimited to the skin.

Collin B, Rajaratnam R, Lim R et al. A retrospective analysis of 34patients with cutaneous sarcoidosis assessed in a dermatologydepartment. Clin. Exper. Dermatol. 2010; 35: 131–4.

NEUROPATHIC MECHANISM FOR PRESSUREULCERS OF THE ELDERLY

The elderly develop cutaneous pressure ulcers due to acombination of external factors, such as pressure, friction,shearing force and moisture, and of internal factors, suchas malnutrition, anaemia and neuropathy. Recent studieshave demonstrated a novel relationship between cutaneousmechano-sensitivity and vasodilation, pressure-inducedvasodilation (PIV). Both humans and mice have demon-strated a vasodilatory response to external pressure appliedto the skin, and recently PIV was shown to be altered in theskin of old mice without neuropathy as opposed to youngmice. This study attempts to determine if the same factorsare present in humans, in whom PIV is mediated by sensoryC-fibres.

PIV in non-neuropathic and neuropathic older subjects(60–75 years) was compared with that of young subjects,20–35 years, using laser Doppler flowmetry to evaluatecutaneous responses to the application of local pressure,acetylcholine and local heating. The non-neuropathic oldersubjects had impaired PIV compared with young subjects(12% vs 62%). Older subjects with quantitative evidence ofperipheral neuropathy had no response at all to PIV. Therewas no difference in the response of epithelial blood flow toacetylcholine in non-neuropathic or neuropathic older sub-jects, and this response was only mildly reduced comparedwith young subjects. This is further confirmation that PIV isa neural function that deteriorates with age, thereby mark-edly increasing the susceptibility of the elderly to pressure-induced ischaemia.

Fromy B, Sigaudo-Roussel D, Gaubert-Dahan M et al. Aging-associated sensory neuropathy alters pressure-induced vasodilationin humans. J. Invest. Dermatol. 2010; 130: 849–55.

A RATIONALE FOR PHOTOTHERAPY INPITYRIASIS ROSEA

Pityriasis rosea (PR), an acute self-limiting eruption affect-ing adolescents and young adults, sometimes requiresactive therapy for either cosmetic reasons, such as anupcoming wedding or social event, or for symptom relief.Although the pathogenesis is unknown, epidemiological,clinical and viral studies suggest the possibility of a reactionto a viral disease. Immunohistochemical studies show thepresence of T cells and Langerhans cells in the dermalinfiltrate of PR lesions, implicating a role for cell-mediatedimmunity. This study compares the histopathological fea-tures of the initial herald patch with fully developed PRlesions in an attempt to further categorize the patho-mechanisms.

Six patients had specimens taken from both the heraldpatch and a secondary patch. The normal skin of patientswith unrelated rashes was used as a control. All specimenswere examined histopathologically with immunohis-tochemical staining with a large panel of monoclonal anti-bodies. All PR specimens showed similar epidermalchanges typical for PR. Dermal findings included increasedCD4+ : CD8+ ratios, as well as increased numbers of Langer-hans cells, with a reduction in natural-killer-cell and B-cellactivity. There was no significant difference between theherald patch and the secondary lesions. The authors con-cluded that the persistence of T-cell-mediated immunityinto established PR lesions provides a rationale for the useof UVB phototherapy in PR that is established and/or slow toresolve, given the role of UVB in suppression of dermalLangerhans cells and T-cell-mediated immunity.

Neoh CY, Tan AWH, Mohamed K et al. Characterization of theinflammatory cell infiltrate in herald patches and fully developederuptions of pityriasis rosea. Clin. Exp. Derm. 2010; 35: 300–4.

SMOKING CESSATION AND WOUND HEALING

Smokers have a higher incidence of wound infection,dehiscence of sutured tissue and loss of tissue flaps.Months to years after surgery, incisional hernias and otherclinical manifestations of incomplete healing are more fre-quent in smokers. Smoking cessation 4 weeks beforesurgery reduces the wound infection rate to the level ofnon-smokers, but improvement of dehiscence is morecontroversial.

In this Danish study, 48 smokers and 30 never smokershad punch biopsy lateral to the sacrum. After 1 week the

Australasian Journal of Dermatology (2010) 51, 218–219 doi: 10.1111/j.1440-0960.2010.00671.x

© 2010 The AuthorJournal compilation © 2010 The Australasian College of Dermatologists

wounds were excised and fixed. Smokers were thenrandomized to continuous smoking with a placebo patchor abstinence with a transdermal nicotine patch. Thesequence of wounding and excision was repeated after 4, 8and 12 weeks, and the excised tissue was examined immu-nohistochemically. Reparative macrophages, fibroblastsand endothelial cells, as well as the inflammatory infiltrate,were assessed. After smoking cessation, the inflammatorycell infiltration and macrophages in the wounds increased,but reparative fibroblasts were unaffected, as was evidenceof neovascularisation. The authors conclude that short-term abstinence from smoking restores inflammation, butdoes not affect proliferation, and therefore explains whysmoking cessation appears to reduce wound infection butnot dehiscence.

Lorenson LT, Toft B, Rygaard J et al. Smoking attenuates woundinflammation and proliferation while smoking cessation restoresinflammation but not proliferation. Wound Repair Regen. 2010; 18:186–92.

ADALIMUMAB FOR NAIL PSORIASIS

Treatment options for nail psoriasis have been disappoint-ing, with topical therapies difficult to use and systemictherapies much less effective than for plaque psoriasis.Earlier reports for the use of biologicals, however, havebeen encouraging. In this open study of adalimumab forsevere plaque psoriasis (PP) and psoriatic arthritis (PA), theresponse of the nails to standard second-weekly injectionsof adalimumab was assessed using the nail psoriasis sever-ity index (NAPSI) and a quality-of-life questionnaire relatingto the impact of nail improvement.

Twenty-one patients (7 PP, 14 PA) completed assessmentsat weeks 0, 12 and 24, with very marked improvement in theNAPSI for both fingernails and toenails. For PP patients,after 24 weeks the mean NAPSI score reduced from 10.57 to1.57 for fingernails, and from 23.86 to 4.14 for toenails. PApatients had reductions from 23.86 to 3.23 for fingernailsand from 29.29 to 10.00 for toenails. All patients were happywith the response of the nails to treatment and this wasreflected in the questionnaire.

The response to treatment with adalimumab confirmsearlier impressions that biologicals represent excellenttreatment for nail psoriasis, in comparison with othertopical and systemic agents.

Rigopoulos D, Tosi A, Luger TA et al. Treatment of nail psoriasiswith adalimumab: an open label unblended study. J. Eur. Acad.Dermatol. Venereol. 2010; 24: 530–4.

TREATING ACNE SCARS WHILE ONISOTRETINOIN

This study raises the possibility that some acne scars canbe safely treated with abrasive therapies while the patientis still on isotretinoin. In the 1980s and 1990s there weremany reports of exaggerated scar formation while patientswere being treated with isotretinoin orally, leading to rec-ommendations that atrophic acne scar revision shouldnot be attempted until 6–12 months after cessation ofisotretinoin.

In this study, seven patients with depressed scars on theface indicated for dermabrasion were treated in an approxi-mately 1-cm2 area using a diamond fraise, not connected toa rotation engine, with strong and controlled pressure toavoid deeper skin injuries. The rationale for this includedrecent experimental evidence that fibroblasts at a deeperlevel seem more likely to produce a hypertrophic scar. Allseven patients showed complete resolution with no compli-cations and satisfactory cosmetic results by day 180. Thelimitations of the study obviously include the low numbersand the modified technique used.

The authors conclude that further studies including full-face dermabrasion are necessary to re-evaluate the waitingtime recommendation, but that a 1-cm2 test area may rep-resent a safe and useful method of selecting candidates.

Bagatin E, dos Santos Guadanhim LR, Yarak S et al. Dermabrasionfor acne scars during treatment with oral isotretinoin. Dermatol.Surg. 2010; 36: 483–9.

Alan WatsonNewcastle, New South Wales, Australia

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© 2010 The AuthorJournal compilation © 2010 The Australasian College of Dermatologists