BACKGROUND AND OBJECTIVES Differences in prevalence, clinical and histological manifestations between seborrheic dermatitis (SD) in immunocompetent and immunocompromised patients suggest that these two populations might also differ in a spectrum of isolated Malassezia species. The purpose of our study was to analyse the prevalence of Malassezia species in immunocompromised and non-immunocompromised patients with SD and to examine if the range of isolated yeasts varies between these two study groups. PATIENTS AND METHODS Specimens were taken from 50 patients with SD: 30 without any underlying disease and 20 with confirmed immunosuppression. The samples were obtained by scraping the skin surface of the scalp and trunk lesions of all subjects and then incubated on modified Dixon agar. The yeasts isolated were identified by their morphological and physiological properties according to Guillot et al method. RESULTS In both groups, the most commonly isolated species from the scalp lesions were Malassenzia restricta and Malassenzia globosa, the later being the most common species isolated from lesional trunk skin. No significant differences were found between immunocompromised and immunocompetent patients from both sampled sites. CONCLUSIONS There is no difference in the distribution of Malassezia species isolated from SD lesions between immunocompetent and immunocompromised patients. However, the much higher percentage of positive cultures in immunocompromised patients confirms that impaired cellular immunity may facilitate fungal survival on the skin.

Scalp involvement is a prominent and often the initial presentation in patients with psoriasis. Hair growth may be impaired with a hair loss and an increased telogen/anagen ratio. The aim of this study was to investigate the hair density and anagen/telogen ratio in psoriatic patients, using epiluminescence microscopy combined with digital image analysis (TrichoScan). Thirty psoriatic patients with scalp involvement and the same number of clinically healthy individuals were included in the study. For the measurement of hair density, anagen/telogen ratio and number of terminal and vellus hairs, a commercially available software TrichoScan was used. Hair density measurements did not show significant difference between patients and controls (P=0.05). The anagen ratio was significantly lower and telogen ratio significantly higher in psoriasis patients than in controls (P<0.01 both). There was no correlation between hair parameters and patient age or duration of disease. Study results support the evidence that scalp psoriasis is associated with an increased telogen/anagen ratio.

Basal cell carcinoma (BCC) is the most frequent malignant skin tumor, which is associated with both genetic factors and environmental influences. The objective of this study was to investigate the risk factors associated with the occurrence of BCC in the inhabitants of the Western Herzegovina area. The study took place during 1997-2003. We examined the risk factors which are presumably associated with the occurrence of BCC: skin type, exposure to UV rays and family occurrence of BCC, supplemented by the examination of the skin type, UV rays and existence of malignant tumors amongst the family members. We recorded a high correlation between the type of skin and the risk of occurrence of BCC. Long term and frequent skin exposure to UV rays were also associated with BCC. We also recorded increased risk for BCC in persons whose family members suffered from malignant skin tumors. Avoiding exposure to the sun as well as protection from UV rays may decrease the risk of BCC.

Alopecia areata (AA) is a heterogeneous disease characterized by nonscarring hair loss on the scalp or other parts of the body. A wide range of clinical presentations can occur-from a single patch of hair loss (alopecia unilocularis, AUl), multiple patches (alopecia multilocularis, AM) to complete loss of hair on the scalp (alopecia totalis, AT) or the entire body (alopecia universalis, AU). The cause ofAA is unknown although most evidence supports the hypothesis that AA is a T-cell mediated autoimmune disease of the hair follicle and that cytokines play an important role. The aim of the study was to evaluate serum concentrations of interferon-gamma (IFN-g) in patients with AA and the healthy subjects and also to assess a possible association between IFN-g and clinical type and duration of the disease. Sixty patients with AA and 20 healthy controls were enrolled in the study. Serum concentrations of IFN-g were determined by ELISA method. The serum concentration of IFN-g in patients with AA was significantly higher than that in the control group (10.62 +/- 1.09 pg/mL vs 10.02 +/- 0.62 pg/mL, respectively). Significantly elevated serum IFN-g were noticed in patients with AU type (11.81 +/- 1.11 pg/mL), expecialy those suffering from AT (12.30 +/- 0.93 pg/mL), compared with both patients with AUl (10.20 +/- 0.59 pg/mL) and patients with AM clinical type (10.21 +/- 0.78 pg/mL). There was no significant difference in serum IFN-g concentration between patients with AUl and AM group, as well as between patients with AT and AU. No correlations were found between duration of disease and the serum levels of IFN-g. Our findings confirm previously published data that the Th1 type cytokine IFN-g is elevated in the serum of AA patients.

Malassezia species are implicated in the pathogenesis of seborrhoeic dermatitis (SD), but the relationship between each species and the disorder remains unclear. It is hypothesised that the pathogenesis of SD has an immune component, which is supported by the increased incidence in patients with immunosuppressive disorders. The purpose of our study was to analyse the prevalence of Malassezia species in lesional skin of SD, and to assess the distribution of the species according to severity of the disease and cellular immune status of the patients. Forty SD patients with scalp involvement were included in the study. The samples were obtained by scraping the skin surface of the scalp and then incubated on Sabouraud dextrose agar and modified Dixon agar. The yeasts isolated were identified by their morphological and physiological properties according to the method of Guillot et al. In addition, we performed two‐colour flow cytometry analysis to investigate the lymphocyte subpopulations in the peripheral blood. The most commonly isolated species was Malassezia restricta (27.5%), followed by Malassezia globosa (17.5%) and Malassezia slooffiae (15%). We demonstrated low helper/suppressor ratios in 70% patients, because of an increase in the suppressor T‐cell population, suggesting an impaired cellular immunity. However, we found no significant difference in the distribution of isolated Malassezia species according to the severity of the scalp involvement and changes in the peripheral blood lymphocyte subpopulations.

Editor Although the paraneoplastic nature of a subset of dermatomyositis (DM) cases is unquestionable, the factors that indicate the coexisting cancer still remain unclear. Several predictive signs have been postulated as a marker of underlying malignancy: older age, male gender, rapid onset of the disease, presence of cutaneous necrosis, increased erythrocyte sedimentation rate (ESR), and increase or normality of creatine phosphokinase (CPK).1–8 In order to identify potential risk factors for associated cancer in patients with DM, we reviewed clinical and laboratory data of 32 patients with DM (17 females and 15 males, aged 11–78 years), who have been treated during a 23-year period (1985–2007). Diagnosis of DM was based on the criteria of Bohan and Peter.9 Typical cutaneous signs and muscular involvement (proximal muscle weakness and/or elevated muscle enzymes and/or electromyography findings and/or muscle histology) were observed in all patients. The main recorded data included an association with a cancer, age at the time of the diagnosis, gender, a rapid onset of symptoms (considered if the diagnosis was made within 3 months after the appearance of initial symptoms), signs of severity (presence of dysphonia, dyspnoea and/or dysphagia), some clinical features such as cutaneous necrosis (defined as cutaneous and/or mucosal necrotic lesions or ulcerations) and periungual erythema, evaluated ESR (superior to 40 mm during the first hour), serum muscle enzymes levels – CPK, lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) – as well as presence of antinuclear autoantibodies. Statistical analysis using Fisher’s exact test for qualitative data and Mann-Whitney’s test for quantitative data were performed to investigate differences between patients with and without associated malignancy. The difference was considered significant at P < 0.05. Malignant tumours were detected in 8 patients (25%), with equal number of female and male patients. Malignancies included colon cancer (2 patients), ovarian cancer (2 patients) and the remaining cancers were those of lung, breast, pancreas and prostate. The prevalence of predicting factors of malignancy is listed in Table 1. Cutaneous necrosis was presenting sign in 76% of our patients with cancer and in only 8.3% of the patients without cancer. Some previously published studies have pointed out that cutaneous necrosis is highly predictive of an associated cancer.3–6 Including our trial, cutaneous necrosis is thought to increase the probability of occult malignancies in 27 (61%) of cases associated with cancer, opposite to 7 (8%) cases of DM without cancer. Since there is no clear definition for the term ‘cutaneous necrosis’, as this skin sign comprises a wide range of symptoms, from small digital necrosis to extensive skin and mucosal necrosis, these results, as pointed out by Burnouf et al.,4 must be analysed with reserve. In our study, elevated muscle enzyme levels were also associated with underlying malignancy, especially elevated level of CPK. The validity of this criterion has been confirmed by most formerly published trials1,4 but is in contrary to some studies that normal muscle enzyme levels tend to be a risk factor in developing cancer.7,8 The observations that the same antigens are expressed at high levels in several cancers known to be associated with the development of inflammatory myopathy, but not in corresponding normal tissue, suggest that the link between malignancy and myositis relates to the expression of common autoantigens between cancer tissue and muscle tissue in patients with DM.10 We can confirm that factors predictive of concomitant malignancy are the presence of cutaneous necrosis and elevation of the muscular enzymes. These parameters, which are easy to evaluate by clinicians, justify the inclusion of an extensive malignancy search that should be orientated by the most frequent localization of cancer.

© 2008 The Authors JEADV 2009, 23, 169–243 Journal compilation © 2008 European Academy of Dermatology and Venereology planus, vitiligo, leg ulcers, pyoderma gangrenosum and steroidinduced rosacea.3 It inhibits cytosine transcription, activates T cells by binding to immunophilins and blocks calcineurin phosphatase activity in the same way as cyclosporin but with a 10–100 times higher potency.4 It also blocks release of histamine from mast cells and penetrates human skin to mediate its activity akin to mid potency topical steroids without any effects on blood vessels. In steroid-induced rosacea, tacrolimus probably mediates its effects through its potent immunosuppressive action and also inhibiting local humoral and cellular immune mechanisms induced by increased microbial counts.4,5 Tacrolimus probably improves rosacea through its strong immunosuppressive effects, as it lacks any significant vascular effects, which may directly counteract vascular disturbances of rosacea.6 This non-steroidal potent topical immunomodulatory agent without inherent adverse effects of topical corticosteroids holds a good promise as an alternative in conditions like rosacea where immunosuppressive effects are required but topical steroids are contraindicated. Further studies having a double-blind and placebo-controlled design are required to ascertain the effective concentration, formulation and duration of therapy with tacrolimus in rosacea.

Malassezia pachydermatis is the only species in the genus Malassezia that is classically considered to be zoophilic. This yeast is only occasionally isolated from human skin, although it has been found to cause septic epidemics, especially in neonates. The aim of our study was to investigate the prevalence of M. pachydermatis on the skin of patients with Malassezia-associated diseases and of healthy subjects. One hundred and sixty skin scrapings from patients with pityriasis versicolor (PV), seborrhoeic dermatitis (SD), psoriasis (PS) and healthy individuals, forty each, were inoculated into Sabouraud dextrose agar and into modified Dixon agar. The yeasts isolated were identified according to their macroscopic and microscopic features and physiological properties. M. globosa was the most commonly isolated species in lesional skin of PV (65%) and PS (55%), M. restricta in lesional skin of SD (27.5%), while M. sympodialis was the predominant species recovered from healthy skin, representing 30% of the isolates. Zoophilic species, M. pachydermatis was identified in only one case, from the lesional skin of SD. The results of our study confirm that M. pachydermatis is not a member of the normal human flora and its presence on human skin is rare and indicates transmission from an external source.

The aim of this study was to determine the incidence and aetiological agents of tinea capitis in Sarajevo area, Bosnia and Herzegovina, during a 10‐year period (1997–2006). A total of 707 patients with suspected dermatophyte infections of scalp was analysed. Tinea capitis was determined in 241 (34.1%) of these patients, in whom causative agents were identified in 209 (29.6%). Zoophilic dermatophytes (91.8%) prevailed over anthropophilic (7.2%) and geophilic (1.0%) dermatophytes. Microsporum canis was the most frequent dermatophyte isolated (90.4%), followed by Trichophyton schoenleinii (2.4%) and Trichophyton violaceum (1.9%). The majority of infections occurred in males (56.5%) and in children with age less than 10 years (52.6%).

Alopecia areata (AA) is disease characterized by focally, nonscaring hair loss on the scalp or any hair-bearing surface. It affects 1-2% population of both genders and occurs at all age groups. The etiology is unknown, although the evidence suggests that AA is a clinical reaction pattern that is the result of combinations of genetic and environmental factors. Effluvium capillorum (EC) is a form of nonscarring diffuse hair shedding. The aim of the study was to determine whether AA is statistically associated with atopy. Sixty patients with AA and 50 patients with EC were enrolled in the study. Presence of atopy was elicited by detailed family and/or personal history of atopy and by intracutaneous tests with the most common atopic allergens. Chi square test was carried out to evaluate statistical significance. 32 (46.7%) of patients with AA were males and 32 (53.3%) females. Majority of them were between 17 and 40 years old. Control group consists of 50 EC patients, 11 (22%) males and 39 (78%) females. Family history of atopy was present in 14 (23.3%) patients with AA, and 6 (12%) with EC (X2=2.37, p>o.05). Evidence of atopy in personal history was present in 16 (26.7%) patients with AA in comparison to control group of 5 (10%) patients, (X2=4.81, p<0.05). Intracoutaneous tests were positive to one or more allergens in 22 (36.7%) with AA compared to 9 (18%) patients with EC (X2=4.70, p<0.05). Based on the family and/or personal history of atopy and intracutaneous tests, we could confirm an atopic constitution in 30% of our AA patients. The frequency of atopy was significantly higher in patients with AA than in controls (30%/10%, X2=6.47, p<0.05). To conclude, our study shows a significant association between AA and atopy.

Pityriasis versicolor (PV) is a superficial fungal infection where Malassezia species play a definite causative role, but the clinical significance of each of these species is not fully understood. The aim of our study was to analyse the prevalence of Malassezia species in PV lesions and to examine if the range of species varies with patient sex, age, direct microscopy findings and some clinical data. Ninety patients with PV completed the study. The samples were obtained by scraping the skin surface, both from lesional and non‐lesional skin and then incubated on Sabouraud dextrose agar and modified Dixon agar. The yeast isolated were identified according to their macroscopic and microscoipic features and physiological characteristics. In PV lesions, the most common species was M. globosa (63%), followed by M. sympodialis (14%), M. furfur (10%), M. obtusa (8%) and M. slooffiae (4%). The most frequently isolated species from clinically healthy skin were M. globosa (49%), M. sympodialis (37%) and M. furfur (5%). We found significant difference in the distribution of Malassezia species between lesional and non‐lesional skin and in the distribution of Malassezia species according to the direct microscopy findings. M. globosa in its mycelial phase is the predominant species involved in the aetiology of PV.

Epidermolytic hyperkeratosis (EHK) or bullous congenital ichthyosiform erythroderma is a rare autosomal dominant disorder characterized by an early onset, with erythroderma and bullous lesions, leading to severe generalized hyperkeratosis in adulthood. Mutations have been found in keratin 1 and keratin 10 genes. The clinical manifestations of EHK present striking heterogeneity and at least six clinical phenotypes have been identified. We report on a case of EHK in a 12-year-old girl with erythroderma, erosions and blisters on the entire body surface at birth and generalized hyperkeratosis but without severe palm and sole involvement in the later stage. On the basis of clinical and histopathologic findings, the diagnosis of EHK type NPS-3 was made.

Alopecia areata (AA) is a heterogeneous disease characterized by nonscarring hair loss on the scalp or any hair-bearing surface. A wide range of clinical presentations can occur, from a single patch of hair loss to complete loss of hair on the scalp (alopecia totalis, AT) or over the entire body (alopecia universalis, AU). The cause of AA is unknown although most evidence supports the hypothesis that AA is an immunologically mediated disease. The aim of the study was to compare serum levels of total immunoglobulin E (IgE) between patients with AA and healthy subjects, and to assess the difference between the localized form and extensive forms of the disease such as AT and AU. Sixty patients with AA and 50 healthy subjects were enrolled in the study. Fifty patients had localized AA (LAA), and ten patients had AT, AU or AT/AU. Serum levels of IgE were measured using fluoroenzyme immunoassay techniques. Serum levels of total IgE were significantly higher in AA patients than in controls (p<0.05). There was no significant difference in serum levels of total IgE between patients with LAA and those with extensive forms of the disease (p>0.05). The exact role of serum IgE in AA should be additionally investigated in future studies.

The progressive increase of zoophilic dermatophytes , especially Microsporum (M.) canis, in the etiology of human dermatophytoses has been observed in many regions in Europe. The aim of our study was to assess the frequency of dermatophytes in Sarajevo area during the period 1998-2005. A total of 3302 samples (skin scrapings, hair, scalp and nail fragments) were collected from patients suspected to have tinea infection and cultured on Sabouraud agar. After three weeks of incubation 633 (19.2%) dermatophytes species were identified based on macroscopic and microscopic morphology. Zoophilic species were found in 554 (87.5%) patients. The most frequent isolated dermatophyte was M. canis (80.3%), followed by Trichophyton (T.) mentagrophytes var. mentagrophytes (6.7%), T. mentagrophytes var. interdigitale (4.7%), Epidermophyton (E.) floccosum (3.0%), T. violaceum (1.4%), T. schoenleinii (1.1%), M. gypseum (0.9%), T. rubrum (0.8%), T. verrucosum (0.6%), T. tonsurans (0.3%) and M. ferrugineum (0.2%). The most common types of M. canis infection were tinea capitis (31.7%) and tinea corporis (26.4%). Our findings indicate increase in the frequency of M. canis infection between 1998 and 2002 and the decline over the last years of the observation period, while rate of other zoophilic species T. mentagrophytes var. interdigitale and T. verrucosum did not change significantly.