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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest a report by Flores-Terry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> published recently in the Actas Dermo-Sifiliogr&#225;ficas journal&#46; The authors reported 2 Spanish female patients with &#34;yellow&#34; facial papules&#40;FP&#41; of frontal fibrosing alopecia&#40;FFA&#41; treated with fixed low dose isotretinoine &#40;i&#46;e&#46; 10<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; One patient showed an excellent response beginning 1 month after starting treatment and persisting up to 6 months&#46; The other patient showed improvement in the patient&#8217;s facial signs after 1&#46;5 months&#44; with a decrease in both the number and extension of FP&#46; The authors stated &#34; There are no data on FP treatment using topical or oral retinoids&#34;&#46; However&#44; this claim is uncertain&#46; We found 3 published papers reported the successful use of low dose isotretinoine in FP in FFA&#47;Lichen plano-pilaris &#40;LPP&#41;&#46; One of these reports studied 62 patients with &#34;yellow&#34; FP&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Frontal fibrosing alopecia &#40;FFA&#41; is considered a variant of lichen planopilaris affecting mainly the frontotemporal hairline&#46; Since the first report in 1994&#44; several other clinical features have been associated with the disease&#44; such as facial papules &#40;FP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Pirmez et al&#46; reported 3 female patients with a biopsy-confirmed FFA&#46; All patients were started on the dosage of 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day of oral isotretinoin for the first month&#44; which was then titrated to 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for the following 2 months &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;day in all 3 patients&#41;&#46; At the end of the first month&#44; a remarkable improvement was noted&#44; with a reduction in the number and size of FP&#46; At the end of the third month&#44; FP had completely disappeared or were considered minimal&#46; Isotretinoin was then discontinued and hydroxychloroquine 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day was introduced&#46; Another interesting point is that the choice of therapeutic regimen seems to affect the time-to response with oral isotretinoin&#46; Although it is not possible to exclude any role of concurrent systemic and topical treatments&#44; the temporal relation between the introduction of oral isotretinoin and the disappearance of the lesions is remarkable&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Of 108 patients with FFA followed by Pedrosa et al&#46;&#44; 62 patients exhibited yellow facial papules&#46; Yellow papules were found on the temporal area&#44; cheeks&#44; chin&#44; or diffusely distributed throughout the face&#46; Histopathologic findings were invariably similar&#44; with hypertrophic sebaceous glands in the papillary dermis with no associated vellus hair follicle or lichenoid inflammation&#46; This observation led to a hypothesize that inflammation eventually resulted in the loss of vellus hair follicles replaced by fibrous scar tissue&#44; whereas the hypertrophic sebaceous glands still remained&#44; giving the clinical appearance of yellow noninflammatory papules on the face devoid of terminal hairs&#46; In all of these patients&#44; the skin was clinically very soft and thin&#44; which made the hypertrophic sebaceous glands shine through or popping up&#46; This finding may have an impact on therapy&#44; because low-dose isotretinoin resulting in sebaceous gland shrinkage could be a valuable option to improve cosmetic appearance in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Those patients were treated with oral low-dose isotretinoin &#40;10<span class="elsevierStyleHsp" style=""></span>mg every other day&#41; for &#8805;12 months&#44; which yielded a visible reduction of the yellow facial papules and was associated with a reduction of skin roughness after a median of 2 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Patients treated with 10<span class="elsevierStyleHsp" style=""></span>mg of isotretinoin every other day reported improvement of skin roughness only after a median of 2 months that was clinically observed after a median of 4 months&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Yellow facial papules present a distinct histologic pattern&#44; which might represent an intermediate step between an initial perifollicular lichenoid inflammation and the ultimate epidermal atrophy without hair follicles but with large sebaceous glands remaining&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Hence&#44; there is a difference between the simple FP and the yellow FP&#59; yellow facial papules involve large sebaceous glands lacking vellus hair follicles and lichenoid inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In a similar vein&#44; Namazi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported 4 cases of famililal LPP presented with isolated &#34;simple&#34; FP&#46; Vellus hair involvement by LPP presenting as facial papules is an uncommon manifestation of LPP&#44; this feature was seen in three of four of their patients&#46; Interestingly&#44; three of the four patients responded well to isotretinoin&#46; One of the 3 responders was on low dose isotretinoin &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; combined with finasteride &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">To sum up&#44; FP has 2 clinical and histopathoogical variants&#59; simple and yellow FP&#46; Both are low-dose isotretinoine responders&#46; The report by Flores-Terry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> represented a cumulative 2 cases with &#34;yellow&#34; FP of FFA responding to a very low dose of isotretinoine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">DECLARATION AUTORIA</p><p id="par0025" class="elsevierStylePara elsevierViewall">Michelangelo Vestita&#58; &#40;1&#41; la concepci&#243;n y el dise&#241;o del estudio&#44; o la adquisici&#243;n de datos&#44; o el an&#225;lisis y la interpretaci&#243;n de los datos&#44; &#40;2&#41; el borrador del art&#237;culo o la revisi&#243;n cr&#237;tica del contenido intelectual&#44; &#40;3&#41; la aprobaci&#243;n definitiva de la versi&#243;n que se presenta&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ayman Abdelmaksoud&#58; &#40;1&#41; la concepci&#243;n y el dise&#241;o del estudio&#44; o la adquisici&#243;n de datos&#44; o el an&#225;lisis y la interpretaci&#243;n de los datos&#44; &#40;2&#41; el borrador del art&#237;culo o la revisi&#243;n cr&#237;tica del contenido intelectual&#44; &#40;3&#41; la aprobaci&#243;n definitiva de la versi&#243;n que se presenta&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding source and conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Letter to the Editor
Reply to «Facial Papules in Frontal Fibrosing Alopecia: Good Response to Isotretinoin»
Ayman Abdelmaksouda, Michelangelo Vestitab,c
a Hospital deDermatología,VenereologíayLeprologíade Mansoura, Mansoura, Egypt
b Unidad de Cirugía Plásticay Reconstructiva, Departamento de Emergenciasy Trasplantede Órganos, Universidad de Bari, Bari, Italy
c Departamento deDermatología, Brighamy Women’s Hospital, Escuelade Medicinade Harvard, Boston, MA
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest a report by Flores-Terry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> published recently in the Actas Dermo-Sifiliogr&#225;ficas journal&#46; The authors reported 2 Spanish female patients with &#34;yellow&#34; facial papules&#40;FP&#41; of frontal fibrosing alopecia&#40;FFA&#41; treated with fixed low dose isotretinoine &#40;i&#46;e&#46; 10<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; One patient showed an excellent response beginning 1 month after starting treatment and persisting up to 6 months&#46; The other patient showed improvement in the patient&#8217;s facial signs after 1&#46;5 months&#44; with a decrease in both the number and extension of FP&#46; The authors stated &#34; There are no data on FP treatment using topical or oral retinoids&#34;&#46; However&#44; this claim is uncertain&#46; We found 3 published papers reported the successful use of low dose isotretinoine in FP in FFA&#47;Lichen plano-pilaris &#40;LPP&#41;&#46; One of these reports studied 62 patients with &#34;yellow&#34; FP&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Frontal fibrosing alopecia &#40;FFA&#41; is considered a variant of lichen planopilaris affecting mainly the frontotemporal hairline&#46; Since the first report in 1994&#44; several other clinical features have been associated with the disease&#44; such as facial papules &#40;FP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Pirmez et al&#46; reported 3 female patients with a biopsy-confirmed FFA&#46; All patients were started on the dosage of 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day of oral isotretinoin for the first month&#44; which was then titrated to 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for the following 2 months &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;day in all 3 patients&#41;&#46; At the end of the first month&#44; a remarkable improvement was noted&#44; with a reduction in the number and size of FP&#46; At the end of the third month&#44; FP had completely disappeared or were considered minimal&#46; Isotretinoin was then discontinued and hydroxychloroquine 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day was introduced&#46; Another interesting point is that the choice of therapeutic regimen seems to affect the time-to response with oral isotretinoin&#46; Although it is not possible to exclude any role of concurrent systemic and topical treatments&#44; the temporal relation between the introduction of oral isotretinoin and the disappearance of the lesions is remarkable&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Of 108 patients with FFA followed by Pedrosa et al&#46;&#44; 62 patients exhibited yellow facial papules&#46; Yellow papules were found on the temporal area&#44; cheeks&#44; chin&#44; or diffusely distributed throughout the face&#46; Histopathologic findings were invariably similar&#44; with hypertrophic sebaceous glands in the papillary dermis with no associated vellus hair follicle or lichenoid inflammation&#46; This observation led to a hypothesize that inflammation eventually resulted in the loss of vellus hair follicles replaced by fibrous scar tissue&#44; whereas the hypertrophic sebaceous glands still remained&#44; giving the clinical appearance of yellow noninflammatory papules on the face devoid of terminal hairs&#46; In all of these patients&#44; the skin was clinically very soft and thin&#44; which made the hypertrophic sebaceous glands shine through or popping up&#46; This finding may have an impact on therapy&#44; because low-dose isotretinoin resulting in sebaceous gland shrinkage could be a valuable option to improve cosmetic appearance in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Those patients were treated with oral low-dose isotretinoin &#40;10<span class="elsevierStyleHsp" style=""></span>mg every other day&#41; for &#8805;12 months&#44; which yielded a visible reduction of the yellow facial papules and was associated with a reduction of skin roughness after a median of 2 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Patients treated with 10<span class="elsevierStyleHsp" style=""></span>mg of isotretinoin every other day reported improvement of skin roughness only after a median of 2 months that was clinically observed after a median of 4 months&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Yellow facial papules present a distinct histologic pattern&#44; which might represent an intermediate step between an initial perifollicular lichenoid inflammation and the ultimate epidermal atrophy without hair follicles but with large sebaceous glands remaining&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Hence&#44; there is a difference between the simple FP and the yellow FP&#59; yellow facial papules involve large sebaceous glands lacking vellus hair follicles and lichenoid inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In a similar vein&#44; Namazi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported 4 cases of famililal LPP presented with isolated &#34;simple&#34; FP&#46; Vellus hair involvement by LPP presenting as facial papules is an uncommon manifestation of LPP&#44; this feature was seen in three of four of their patients&#46; Interestingly&#44; three of the four patients responded well to isotretinoin&#46; One of the 3 responders was on low dose isotretinoin &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; combined with finasteride &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">To sum up&#44; FP has 2 clinical and histopathoogical variants&#59; simple and yellow FP&#46; Both are low-dose isotretinoine responders&#46; The report by Flores-Terry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> represented a cumulative 2 cases with &#34;yellow&#34; FP of FFA responding to a very low dose of isotretinoine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">DECLARATION AUTORIA</p><p id="par0025" class="elsevierStylePara elsevierViewall">Michelangelo Vestita&#58; &#40;1&#41; la concepci&#243;n y el dise&#241;o del estudio&#44; o la adquisici&#243;n de datos&#44; o el an&#225;lisis y la interpretaci&#243;n de los datos&#44; &#40;2&#41; el borrador del art&#237;culo o la revisi&#243;n cr&#237;tica del contenido intelectual&#44; &#40;3&#41; la aprobaci&#243;n definitiva de la versi&#243;n que se presenta&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ayman Abdelmaksoud&#58; &#40;1&#41; la concepci&#243;n y el dise&#241;o del estudio&#44; o la adquisici&#243;n de datos&#44; o el an&#225;lisis y la interpretaci&#243;n de los datos&#44; &#40;2&#41; el borrador del art&#237;culo o la revisi&#243;n cr&#237;tica del contenido intelectual&#44; &#40;3&#41; la aprobaci&#243;n definitiva de la versi&#243;n que se presenta&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding source and conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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