Several prospective studies on dermatological findings in human immunodeficiency virus (HIV) type 1 infected patients have been published, mostly in populations in which the predominant risk factor for HIV infection is homosexuality. We attempted to identify cutaneous diseases associated with HIV-1 infection and to assess disease progression in a cohort of Spanish patients in whom the predominant cause of HIV infection was intravenous drug abuse. We prospectively examined 1161 HIV-1-positive patients for 38 months. Seventy-four per cent of patients were intravenous drug abusers, whereas heterosexual contact was the only risk factor in 14% and homosexuality in 9%. Centers for Disease Control stage II disease predominated (51%), whereas stage IV disease was less frequent (39%). The mean CD4 count was 353/mm3. We took patients' past and present medical history and performed a complete physical examination as well as taking photographs and carrying out the necessary diagnostic procedures. CD4 counts/mm3 were measured at each visit. A diagnosis of cutaneous disease was made in 799 patients (69%). Oral candidiasis and seborrhoeic dermatitis were the most common skin disorders, followed by xerosis, drug eruptions, dermatophytosis and the papular eruption of acquired immunodeficiency syndrome. Condyloma acuminatum, herpes zoster and herpes simplex were the most frequent viral infections. Conditions that have a statistically significant association with advanced stage and low CD4 levels include drug eruptions, xerosis, light reactions, diffuse alopecia, herpes simplex, oral candidiasis, psoriasis, oral hairy leucoplakia, molluscum contagiosum, Kaposi's sarcoma, furuncles, candidal intertrigo, folliculitis and ungual infection, as well as onychomycosis and tinea pedis or manuum. Dermatoses commonly associated with homosexuality, such as Kaposi's sarcoma and oral hairy leucoplakia, were rare in our patients.

Although the results of some studies have proven negative, the influence of psychological factors in the development, evolution and therapeutic management of alopecia areata is, in general, well documented. Life events and intrapsychically generated stress can play an important role in triggering of some episodes. The comorbidity of psychiatric disorders, mainly generalized anxiety disorder, depression, and phobic states, is high. The role of treatment of concomitant psychopathological disorders is a vital one. Indeed this treatment can positively affect how the patient adapts to his/her alopecia and social setting and perhaps can even lead to a better dermatological evolution of the alopecia. Therefore, controlled studies analyzing the possible links between psychiatric symptoms, treatment with antidepressants or benzodiacepines, evolution of alopecia, medium term prognosis, and immune function are necessary. Basic psychotherapeutic support may prove to be of use in many cases and can be carried out by the dermatologist, although a subgroup of patients may need psychopharmacological or psychotherapeutic specialized treatments. Studies using operative diagnostic criteria and structured interviews are still scarce. Therefore, it seems necessary to design studies using modern psychiatric methodology. Controlled clinical trials to test the efficiency of psychoactive drugs and psychotherapy in the disease are also needed. By studying in depth these and other related aspects, we may improve the clinical management of our patients.

Trichotillomania is as medical condition caused by the patient himself by pulling out of is own hair, resulting in a perceptible hair loss pattern that frequently is associated with other psychiatric processes. Generally has a chronic course in most patients, and a challenging therapeutical management. There are several available options for is treatment, but the clinical response is not satisfactory in many patients. Recently, N-acetylcisteine, a glutamate modulator, has shown efficacy in the treatment of trichotillomania and other compulsive behaviors, and is considered a new alternative in the management of this condition. We describe two patients with trichotillomania successfully treated with N-acetylcysteine. Nevertheless, further studies need to be conducted to establish the appropriate treatment regimen and to evaluate it long-term efficacy in improving this chronic condition.

According to this study, BAA may progress to scalp AA in a significant number of patients (45.5% of the patients with a follow-up interval of at least 12 months). In the group of patients who developed scalp AA, 80% of them did it within the first 12 months, so follow-up of patients with BAA is highly encouraged.