Journal of the American Academy of Dermatology

Urticarial lesions: If not urticaria, what else? The differential diagnosis of urticaria: Part I. Cutaneous diseases

Anna Peroni, Chiara Colato, Donatella Schena, Giampiero Girolomoni — 2010-04-01

Acute urticaria is self-limiting, and a cause can be identified in many patients. Chronic urticaria is a long lasting disease, and patients are commonly examined for an autoimmune origin and for associated diseases. Although the diagnosis of urticaria is straightforward in most patients, it may pose some difficulties at times and it may require a careful differential diagnosis with a number of conditions. Urticarial syndromes comprise both cutaneous and systemic disorders. Part I of this two-part series focuses on the clinical and histologic features that characterize common urticaria and on the cutaneous diseases that may manifest with urticarial lesions and must be considered in the differential diagnosis.Learning objectives: After completing the learning activity, participants should be able to distinguish between the typical wheals of urticaria and urticarial lesions suggesting other diagnoses and to assess patients with urticarial lesions in order to exclude or confirm other cutaneous diseases.

Answers to CME examination

2010-04-01

CME examination

2010-04-01

Urticarial lesions: If not urticaria, what else? The differential diagnosis of urticaria: Part II. Systemic diseases

Anna Peroni, Chiara Colato, Giovanna Zanoni, Giampiero Girolomoni — 2010-04-01

There are a number of systemic disorders that can manifest with urticarial skin lesions, including urticarial vasculitis, connective tissue diseases, hematologic diseases, and autoinflammatory syndromes. All of these conditions may enter into the differential diagnosis of ordinary urticaria. In contrast to urticaria, urticarial syndromes may manifest with skin lesions other than wheals, such as papules, necrosis, vesicles, and hemorrhages. Lesions may have a bilateral and symmetrical distribution; individual lesions have a long duration, and their resolution frequently leaves marks, such as hyperpigmentation or bruising. Moreover, systemic symptoms, such as fever, asthenia, and arthralgia, may be present. The most important differential diagnosis in this group is urticarial vasculitis, which is a small-vessel vasculitis with predominant cutaneous involvement. Systemic involvement in urticarial vasculitis affects multiple organs (mainly joints, the lungs, and the kidneys) and is more frequent and more severe in patients with hypocomplementemia. Clinicopathologic correlation is essential to establishing a correct diagnosis.Learning objectives: After completing the learning activity, participants should be able to distinguish urticarial lesions suggesting diagnoses other than common urticaria; assess patients with urticarial lesions, and suspect systemic diseases presenting with urticarial skin lesions.

CME examination

2010-04-01

Answers to CME examination

2010-04-01

American Board of Dermatology Examination Dates

2010-04-01

Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: Results of two placebo-controlled studies of daily application to the face and balding scalp for two 3-week cycles

2010-02-04

Background: Imiquimod 5% cream is approved as a 16-week regimen for the treatment of actinic keratoses involving a 25-cm2 area of skin.Objective: We sought to evaluate imiquimod 2.5% and 3.75% creams for short-course treatment of the entire face and scalp.Methods: In two identical studies, adults with 5 to 20 lesions were randomized to placebo, or imiquimod 2.5% or 3.75% cream (1:1:1). Up to two packets (250 mg each) were applied per dose once daily for two 3-week treatment cycles, with a 3-week, no-treatment interval. Efficacy was assessed at 8 weeks posttreatment.Results: In all, 490 subjects were randomized to placebo, or imiquimod 2.5% or 3.75% cream. Median baseline lesion counts for the treatment groups were 9 to 10. Complete and partial clearance rates were 5.5% and 12.8% for placebo, 25.0% and 42.7% for imiquimod 2.5%, and 34.0% and 53.7% for imiquimod 3.75% (P < .001, each imiquimod vs placebo; P = .034, 3.75% vs 2.5% for partial clearance). Median reductions from baseline in lesion count were 23.6%, 66.7%, and 80.0% for the placebo, imiquimod 2.5%, and imiquimod 3.75% groups, respectively (P < .001 each imiquimod vs placebo). There were few treatment-related discontinuations. Temporary treatment interruption (rest) rates were 0%, 17.1%, and 27.2% for the placebo, imiquimod 2.5%, and imiquimod 3.75%, respectively.Limitations: Local effects of imiquimod, including erythema, may have led to investigator and subject bias.Conclusions: Both imiquimod 2.5% and 3.75% creams were more effective than placebo and had an acceptable safety profile when administered daily as a 3-week on/off/on regimen.

Volunteers Needed

2010-04-01

Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: Results of two placebo-controlled studies of daily application to the face and balding scalp for two 2-week cycles

2010-02-04

Background: The approved imiquimod 5% cream regimen for treating actinic keratoses requires a long treatment time and is limited to a small area of skin.Objective: We sought to evaluate imiquimod 2.5% and 3.75% for short-course treatment of the full face or balding scalp.Methods: In two identical studies, adults with 5 to 20 lesions were randomized to placebo, imiquimod 2.5%, or imiquimod 3.75% (1:1:1). Up to two packets (250 mg each) were applied per dose once daily for two 2-week treatment cycles, with a 2-week, no-treatment interval between cycles. Efficacy was assessed at 8 weeks posttreatment.Results: A total of 479 patients were randomized to placebo, or imiquimod 2.5% or 3.75%. Complete and partial clearance (≥75% lesion reduction) rates were 6.3% and 22.6% for placebo, 30.6% and 48.1% for imiquimod 2.5%, and 35.6% and 59.4% for imiquimod 3.75%, respectively (P < .001 vs placebo, each; P = .047, 3.75% vs 2.5% for partial clearance). Median reductions from baseline in lesion counts were 25.0% for placebo, 71.8% for imiquimod 2.5%, and 81.8% for imiquimod 3.75% (P < .001, each active vs placebo; P = .048 3.75% vs 2.5%). There were few treatment-related discontinuations. Patient rest period rates were 0% for placebo, 6.9% for imiquimod 2.5%, and 10.6% for imiquimod 3.75%.Limitations: Local pharmacologic effects of imiquimod, including erythema, may have limited concealment of treatment assignment in some patients.Conclusions: Both imiquimod 2.5% and 3.75% creams were more effective than placebo and were well tolerated when administered daily as a 2-week on/off/on regimen to treat actinic keratoses.

Low rates of clinical recurrence after biopsy of benign to moderately dysplastic melanocytic nevi

Agnessa Gadeliya Goodson, Scott R. Florell, Kenneth M. Boucher, Douglas Grossman — 2009-12-17

Background: Little is known about the recurrence/persistence rates of dysplastic nevi (DN) after biopsy, and whether incompletely removed DN should be re-excised to prevent recurrence.Objective: Our purpose was to determine the recurrence rates of previously biopsied DN, and to assess whether biopsy method, margin involvement, congenital features, epidermal location, and degree of dysplasia are associated with recurrence.Methods: Patients having a history of a “nevus biopsy” at least 2 years earlier were assessed for clinical recurrence. Slides of original lesions were re-reviewed by a dermatopathologist.Results: A total of 271 nevus biopsy sites were assessed in 115 patients. Of 195 DN with greater than 2 years of follow-up, 7 (3.6%) demonstrated recurrence on clinical examination. In all, 98 DN had a follow-up period of at least 4 years with no clinical recurrence. Of 61 benign nevus biopsy sites examined, clinical recurrence was observed in two (3.3%). For all nevi, recurrence was significantly associated with shave biopsy technique but not with nevus dysplasia or subtype, or the presence of positive margin or congenital features.Limitations: Most biopsies were performed in a pigmented lesion clinic at a single tertiary referral center. Determinations of nevus recurrence were made on clinical rather than histologic grounds, and follow-up times were limited in some cases.Conclusion: In this cohort, rates of clinical recurrence after biopsy of DN and benign nevi were extremely low. Re-excision of nevi, including mildly to moderately DN with a positive margin, may not be necessary.

Dermatoscopy of pigmented Bowen's disease

Alan Cameron, Cliff Rosendahl, Philipp Tschandl, Elisabeth Riedl, Harald Kittler — 2010-01-18

Background: Pigmented Bowen's disease is not well characterized.Objective: To characterize the clinical and dermatoscopic appearance of pigmented Bowen's disease.Methods: We performed a retrospective analysis of 52 consecutive cases of pigmented Bowen's disease.Results: Of 951 histopathologically verified cases of Bowen's disease that underwent biopsy during the study period, 52 (5.5%) were pigmented. Dermatoscopically pigmented Bowen's disease is typified by a pattern of dots and/or structureless zones. In 21.2% (n=11), we observed brown or gray dots arranged in a linear fashion. Vessels were identified in 67.3% of lesions with a predomination of coiled vessels. A linear arrangement of vessels was seen in 11.5%.Limitations: Conclusions are limited by the fact that this was a retrospective, uncontrolled study.Conclusions: Pigmented Bowen's disease has a characteristic dermatoscopic pattern. Linear arrangement of brown and/or gray dots and/or coiled vessels is a specific clue to pigmented Bowen's disease.

A 20-year analysis of previous and emerging allergens that elicit photoallergic contact dermatitis

Frank C. Victor, David E. Cohen, Nicholas A. Soter — 2010-02-17

Background: Retrospective chart reviews are periodically needed to update allergen series to detect changes in photoallergic contact dermatitis (PACD) over time.Objective: We sought to evaluate photopatch test results during a 13-year period and extend the observations to 20 years.Methods: A retrospective chart review was conducted in patients who were photopatch tested.Results: In all, 76 patients were evaluated. A total of 69 positive photopatch and 45 positive patch test reactions were detected in 30 and 23 patients, respectively. The frequencies of the positive photopatch test reactions were sunscreens 23.2%, antimicrobial agents 23.2%, medications 20.3%, fragrances 13%, plants and plant derivatives 11.6%, and pesticides 8.7%. Of the positive photopatch reactions to antimicrobial agents, 60% were caused by Fentichlor.Limitations: This study was a retrospective chart analysis, and the number of patients was small.Conclusions: Sunscreens and antimicrobial agents were the most frequent allergens eliciting PACD, and there was a decrease in PACD caused by fragrances. The number of reactions to medications increased. This study also demonstrated that pesticides can be a cause of PACD. The detection of reactions to Fentichlor was unexpected and, although they have been attributed in some studies to cross-reactions to sulfanilamides and bithionol, such a robust association was not observed in this study. This study extends our experience of the changes in the allergens that elicit PACD to 20 years.

Online Images in Dermatology Will Return Soon

2010-04-01

Orofacial granulomatosis: Clinical features and long-term outcome of therapy

2010-02-05

Background: Orofacial granulomatosis (OFG) is a chronic inflammatory disorder characterized by persistent or recurrent soft tissue enlargement, oral ulceration, and a variety of other orofacial features. There remain few detailed reports of the clinical features and long-term response to therapy of substantial groups of patients with OFG.Objective: The aim of this study was to determine retrospectively the clinical, hematologic, and histopathological features of a large case series of patients with OFG. In addition the long-term response to therapy was examined.Methods: Clinically relevant data of 49 patients with OFG who attended a single oral medicine unit in the United Kingdom were retrospectively examined. The analyzed parameters included diagnostic features, clinical manifestations, and outcomes and adverse side effects of therapy.Results: Labial swelling was the most common presenting clinical feature at diagnosis (75.5%), followed by intraoral mucosal features other than ulceration such as cobblestoning and gingival enlargement (73.5%). Mucosal ulceration was observed in 36.7% of patients whereas extraoral facial manifestations such as cutaneous erythema and swelling were present in 40.8% of patients. Of the 45 patients who required treatment, 24 (53.3%) were treated with topical corticosteroids/immunosuppressants only, whereas 21 (46.7%) received a combined therapy (topical plus systemic corticosteroids/immunosuppressants and/or intralesional corticosteroids). The long-term outcome analysis showed complete/partial resolution of tissue swelling and oral ulceration in 78.8% and 70% of patients, respectively.Limitations: The main limitation of the current study was its retrospective design and methodology including differences in reporting clinical features and outcome.Conclusions: OFG can show multiple facial and mucosal clinical features. Long-term treatment with topical and/or combined therapy is needed in the majority of patients. Response to therapy is highly variable even though in the long-term complete/partial disease resolution can be obtained in the majority of patients. Mucosal ulceration tends to be more recalcitrant than orofacial swelling. Adverse side effects of therapy are rare.

Platelet activation in patients with psoriasis: Increased plasma levels of platelet-derived microparticles and soluble P-selectin

Risa Tamagawa-Mineoka, Norito Katoh, Saburo Kishimoto — 2009-12-07

Background: It has recently been established that platelets have an important role in increasing inflammation, in addition to their main role in hemostasis and thrombosis. An increased incidence of occlusive vascular disease has been reported in patients with psoriasis and the pathomechanism of psoriasis may involve platelet activation.Objective: The goal of the study was to establish a clearer explanation of the association between platelet activation and psoriasis activity by investigating the levels of markers of platelet activation in patients with psoriasis and examining the relationship between the marker levels and a severity score for psoriasis.Methods: Plasma levels of platelet-derived microparticles (PDMPs) and soluble P-selectin were measured by enzyme-linked immunosorbent assay as markers of platelet activation in 21 patients with psoriasis and 22 healthy control subjects. The relationships between the platelet activation markers and the Psoriasis Area and Severity Index score were investigated.Results: Plasma PDMPs and soluble P-selectin levels were markedly higher in patients with psoriasis compared with those in healthy control subjects. There was a significant correlation between the PDMPs levels and the Psoriasis Area and Severity Index score, and the increased plasma PDMPs and soluble P-selectin levels were markedly reduced after clinical improvement occurred.Limitations: The number of people evaluated was relatively small.Conclusions: Our results show that blood platelets are activated in patients with psoriasis, especially in those with extensive disease, and suggest a close association between platelet activation and psoriasis activity. Plasma PDMPs level may be a useful indicator of the severity of psoriasis.

Midline/paramedian longitudinal matrix excision with flap reconstruction: Alternative surgical techniques for evaluation of longitudinal melanonychia

Siobhan C. Collins, Katharine B. Cordova, Nathaniel J. Jellinek — 2010-04-01

Background: Surgical evaluation of longitudinal melanonychia requires biopsy of the nail matrix. Previous publications have presented detailed surgical approaches to this problem. However, discussion of longitudinal excision with local matrix flap reconstruction is documented sparsely in the literature.Objective: To describe the indications for and technique of performing a longitudinal, full-thickness excision for longitudinal melanonychia; as this surgery poses a high risk of postoperative split nail, reconstruction is essential. Three local matrix flaps are detailed to maximize functional and cosmetic results.Methods: The authors detail the different procedures, with several illustrations and clinical photographs highlighting the techniques.Results: These techniques provide the surgeon with additional approaches to excise lesions of longitudinal melanonychia and reconstruct the surgical defects.Limitations: All surgeries of the nail matrix pose a risk of postoperative nail dystrophy and/or split nail.Conclusion: The different flaps provide elegant local alternatives to second-intention healing and maximize cosmetic and functional results after matrix excision with narrow margins for longitudinal melanonychia.

Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser

2010-04-01

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving the intertriginous areas.Objective: We sought to conduct clinical and histopathologic evaluation of the efficacy of long-pulsed neodymium:yttrium-aluminium-garnet laser treatment for HS.Methods: We conducted a prospective, randomized, right-left within-patient controlled trial for HS (n = 22). Four monthly laser sessions were performed. Disease activity was measured at baseline, and treatment response was assessed before each laser session and monthly for 2 months after the completion of laser treatment, using a modified scoring system based on Sartorius score. Histologic examination was performed at baseline, immediately after laser treatment, and at 1 and 4 weeks after treatment. A patient questionnaire was circulated on the last visit to assess patients' level of satisfaction.Results: There was progressive improvement in disease activity, most significantly during the 4 months of treatment, which was maintained during the 2-month posttreatment follow-up period. Averaged over all anatomic sites, the percent improvement was 72.7% on the laser treated side, and 22.9% on the control side (P < .05). Histologic examination showed an initial acute neutrophilic infiltrate. Granulomatous inflammation was present on follow-up biopsy specimens 4 weeks later. An inflammatory infiltrate surrounded the hair shaft remnants, denoting destruction of hair follicles.Limitations: Small sample size was a limitation.Conclusions: Long-pulsed neodymium:yttrium-aluminium-garnet laser, together with topical benzoyl peroxide and clindamycin, is significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS. Preliminary review of histopathology suggests the mechanism of action is destruction of the hair follicle. The overall success of the treatment in both clearing pre-existing lesions and preventing new eruptions, coupled with high patient satisfaction, makes the neodymium:yttrium-aluminium-garnet laser a promising treatment advance for this highly disabling condition.

Pyoderma gangrenosum: A review and update on new therapies

2010-04-01

Pyoderma gangrenosum is a rare and often painful skin disease that can be unpredictable in its response to treatment. There is currently no gold standard of treatment or published algorithm for choice of therapy. The majority of data comes from case studies that lack a standard protocol not only for treatment administration but also for the objective assessment of lesion response to a specific therapy. This review provides an update to the treatment of pyoderma gangrenosum with a particular focus on new systemic therapies.

Treatment of erythrodermic psoriasis: From the medical board of the National Psoriasis Foundation

2009-08-10

Background: Erythrodermic psoriasis is a severe form of psoriasis that can arise acutely or follow a chronic course. There are a number of treatment options, but overall there are few evidence-based data to guide clinicians in managing these challenging cases.Objective: Our aim was to create treatment recommendations to help dermatologists treat patients with erythrodermic psoriasis.Methods: A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options for erythrodermic or exfoliative psoriasis. Meetings were held by teleconference and were coordinated and funded by the National Psoriasis Foundation. Consensus on treatment of erythrodermic psoriasis was achieved. A literature review was conducted to examine treatment options for erythrodermic psoriasis and the strength of the evidence for each option.Results: There is no high-quality scientific evidence on which to base treatment recommendations. Treatment should be dictated by the severity of disease at time of presentation and the patient's comorbidities. Cyclosporine and infliximab appear to be the most rapidly acting agents for the treatment of erythrodermic psoriasis. Acitretin and methotrexate are also appropriate first-line choices, although they usually work more slowly. Treating physicians can consider a number of second-line agents, including etanercept or combination therapy, in the treatment of patients with erythrodermic psoriasis. Combination therapy may be more effective than a single-agent approach; there is a paucity of scientific data in this area. All patients should be evaluated for underlying infection. Supportive care can help control disease and patient symptoms if instituted appropriately. Physicians should avoid potential exacerbating agents when managing this challenging disease.Limitations: There are few high-quality studies examining treatment options for erythrodermic psoriasis.Conclusion: Treatment of patients with erythrodermic psoriasis demands a thorough understanding of the treatment options available. Therapy should be based on acuity of disease and the patient's underlying comorbidities. There are limited data available to compare treatment options for erythrodermic psoriasis. Further studies are necessary to explore the optimal treatment algorithm for these patients.

Antioxidants and their chemopreventive properties in dermatology

Jacqueline M. Junkins-Hopkins — 2010-04-01

Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editor-in-Chief Jacqueline M. Junkins-Hopkins, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology.

Erratum

2010-04-01

Hossler EW. Caterpillars and moths. Part I. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol 2010;62:1-10. Hossler EW. Caterpillars and moths. Part II. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol 2010;62:13-28.

Change of Address

2010-04-01

Periorbital mucinosis: A variant of cutaneous lupus erythematosus?

2010-02-12

Lupus erythematosus has a wide spectrum of cutaneous manifestations, including periorbital mucinosis. We report 3 cases of periorbital mucinosis occurring in association with other cutaneous signs of lupus erythematosus. Based on a review of the literature, periorbital mucinosis is a rare and not widely recognized clinical manifestation of the disease. Although unusual, familiarity with periorbital mucinosis as a manifestation of lupus erythematosus broadens our understanding of these entities and expands the spectrum of cutaneous lupus erythematosus.

Bisphosphonate-related osteonecrosis of the jaw presenting as a cutaneous dental sinus tract: A case report and review of the literature

Sam V. Truong, Linda C. Chang, Timothy G. Berger — 2010-02-12

Bisphosphonates are endogenous pyrophosphate analogs that work to inhibit osteoclast activity. They are commonly used in the treatment of patients with bone related diseases, such as solid tumor metastasis and osteoporosis. One of the infrequent but not rare side effects, especially with high doses of bisphosphonates, is osteonecrosis of the jaw. Although predominantly recognized by dentists because of the bony and intraoral manifestations of the disease, it may also present on the skin. We present a case of osteonecrosis of the jaw resembling two flesh-colored papules associated with dental sinus tracts to highlight the clinical manifestations that dermatologists may encounter, and review the literature on this rare but morbid condition.

Coexistent Kaposi sarcoma, cryptococcosis, and Mycobacterium avium intracellulare in a solitary cutaneous nodule in a patient with AIDS: Report of a case and literature review

Thomas A. Pietras, Christian L. Baum, Brian L. Swick — 2010-04-01

We present a report of a 63-year-old man with AIDS who was diagnosed with coexistent Kaposi sarcoma (KS), Cryptococcus neoformans, and Mycobacterium avium intracellulare in a single, solitary lesion. A literature review identified 11 cases of patients with AIDS and cutaneous lesions with co-existent KS and other infectious organisms. To our knowledge, this is the first report of coexistent KS, C neoformans, and M avium intracellulare in the same cutaneous lesion in a patient with AIDS.

A case of lymphoepithelioma-like carcinoma of the skin associated with Epstein–Barr virus infection

2010-04-01

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm with histopathologic similarities to nasopharyngeal carcinoma. The association of nasopharyngeal carcinoma with Epstein–Barr virus (EBV) is well documented. EBV has also been reported to be associated with LELC in only four sites (the stomach, salivary glands, lung, and thymus), but not in the skin. We report herein a case of EBV-positive LELCS. An 82-year-old female presented with a red nodule on the right cheek. Histologically, the entire dermis was occupied by atypical tumor cell nests with dense lymphocytic infiltration. Neoplastic cells were strongly positive for cytokeratin 14 but were negative for cytokeratins 19 and 20. EBV genomes in neoplastic cells were detected by polymerase chain reaction analysis and in situ hybridization for EBV-encoded RNA, suggesting an association with EBV.

Comparison of advertising strategies between the indoor tanning and tobacco industries

Jennifer Greenman, David A. Jones — 2010-02-08

The indoor tanning industry is large and continues to grow, with 2007 domestic sales in excess of $5 billion. Advertising is central to shaping the consumer's perception of indoor tanning as well as driving industry demand. This article aims to identify key drivers of consumer appeal by comparing tanning advertising strategies to those used by tobacco marketers. Tobacco advertising was selected as a reference framework because it is both well documented and designed to promote a product with known health hazards. Two thousand advertisements from 4 large tobacco advertisement databases were analyzed for type of advertisement strategy used, and 4 advertising method categories were devised to incorporate the maximum number of advertisements reviewed. Subsequently, contemporary tanning advertisements were collected from industry magazines and salon websites and evaluated relative to the identified strategy profiles. Both industries have relied on similar advertising strategies, including mitigating health concerns, appealing to a sense of social acceptance, emphasizing psychotropic effects, and targeting specific population segments. This examination is a small observational study, which was conducted without rigorous statistical analysis, and which is limited both by the number of advertisements and by advertising strategies examined. Given the strong parallels between tobacco and tanning advertising methodologies, further consumer education and investigation into the public health risks of indoor tanning is needed.

Systematic review of the safety of topical corticosteroids in pregnancy

Ching-Chi Chi, Shu-Hui Wang, Gudula Kirtschig, Fenella Wojnarowska — 2010-02-01

Background: Pregnant women may have skin conditions that require topical corticosteroids. However, little is known about their safety in pregnancy.Objective: We sought to evaluate the available evidence concerning the safety of topical corticosteroids in pregnancy.Methods: We systematically searched 17 databases and trial registers, and contacted pharmaceutical companies. Randomized controlled trials and cohort studies of topical corticosteroids in pregnant women, and case-control studies comparing maternal exposure to topical corticosteroids between patients and control subjects were included. The Newcastle-Ottawa Scale was used for quality assessment of included studies.Results: Seven studies, including two cohort and five case-control studies, were included. Most studies did not find significant associations of topical corticosteroids with congenital abnormality, preterm delivery stillbirth, and mode of delivery. One study found a significant association between first-trimester use of topical corticosteroids and orofacial cleft, and another study found a significant association between very potent topical corticosteroids and low birthweight.Limitations: The available data were limited and mainly on orofacial cleft. The quality of evidence was generally low.Conclusions: Currently limited and inconclusive data are unable to detect an association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth. The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids. However, there does appear to be an association of very potent topical corticosteroids with low birthweight. Further cohort studies with comprehensive outcome measures, consideration of corticosteroid potency, dosage and indications, and a large sample size are needed.

Concern regarding the safety of tumor necrosis factor-alfa antagonists in pregnancy

Andrew Miner — 2010-04-01

To the Editor: Choosing appropriate, safe treatment for pregnant patients with psoriasis can be challenging. Although tumor necrosis factor–alfa (TNFα) antagonists are considered category B drugs according to the US Food and Drug Administration (FDA), Carter et al reported a disturbing association of infliximab and etanercept with congenital anomalies associated with the vertebral, anal, cardiovascular, tracheoesophageal, renal, limb (VACTERL) syndrome. In their review of more than 120000 adverse events of patients on TNFα antagonist therapy, they found 61 congenital anomalies occurring at higher than expected frequencies. No reports of congenital anomalies were reported in patients taking adalimumab; however, the database included entries only through 2005, which was relatively soon after adalimumab received approval by the FDA. This suggests that caution should be exercised in prescribing TNFα antagonists in pregnancy despite their category B status.

Hidradenitis suppurativa markedly decreases quality of life and professional activity

Łukasz Matusiak, Andrzej Bieniek, Jacek C. Szepietowski — 2010-04-01

To the Editor: We read with great interest the comprehensive review by Alikhan et al in the April 2009 issue of the Journal and would like to comment on our own recent findings regarding hidradenitis suppurativa (HS) and the Dermatology Life Quality Index (DLQI).

The 3S technique: Another minimally invasive technique in the treatment of saphenous varicose veins

Sami Abdennader — 2010-04-01

To the Editor: I read with interest the article by Nijsten et al in the January 2009 issue of the Journal that describes three minimally invasive techniques in the treatment of saphenous varicose veins: foam sclerotherapy, endovenous laser therapy, and radiofrequency ablation. Another procedure—the 3S saphenectomy (the 3S technique)—should be added to theses techniques. The 3S technique associates the surgical sectioning and sclerotherapy of saphenous veins under local anesthesia. It has been developed in France mainly by Vin et al. Many angiophlebologists learned this technique during the educational program of the European School of Phlebology in Paris. It is useful in the following instances: (1) when surgery is not recommended because of an advanced age and/or in case of a leg ulcer or other complication; (2) when surgery is refused for a personal reason; and (3) when the varicose veins are too large to be treated with classical sclerotherapy. In selected cases, the 3S technique gives good results and should be completed by sclerotherapy in the distal portion of the saphenous veins. Moreover, in a study conducted in Spain, this technique decreased the overall rate of recurrence when compared to classical surgery (stripping).

Sentinel node biopsy: Not the standard of care for melanoma

2010-04-01

To the Editor: The International Sentinel Node Society (ISNS) opinion, that sentinel node biopsy (SNB) “is standard of care,” is not supported by clinical evidence and warrants scrutiny. Their commentary contradicts recent multidisciplinary Australian guidelines that state that “Patients with a melanoma greater than 1.0 mm in thickness be given the opportunity to discuss SNB to provide staging and prognostic information” but deliberately do not state that SNB should be considered standard of care.

Narrowband ultraviolet B phototherapy influences serum folate levels in patients with vitiligo

Jenny E. Murase, John Y.M. Koo, Timothy G. Berger — 2010-04-01

To the Editor: We read with interest the article by Rose et al in the August 2009 issue of the Journal. Ultraviolet B light phototherapy (UVB) is generally considered the safest form of systemic psoriasis therapy in pregnancy. We commend the authors for creating a study to examine the photodegradation of serum folate after exposure to narrowband UVB (nbUVB), given that folate deficiency in the first trimester of pregnancy could predispose to the development of neural tube defects.

Myxoinflammatory fibroblastic sarcoma on the thigh

Kim Bui, Sarah Glorioso, Thomas Nicotri, Jeffrey Frederic — 2010-04-01

To the Editor: Myxoinflammatory fibroblastic sarcoma (MIFS) is a slow growing, low grade tumor reported as a soft tissue tumor affecting the distal extremities. It was first described in 1998 by Meis-Kindblom and Kindblom and Montgomery et al. Although it was described by different names—acral MIFS and inflammatory myxohyaline tumor of distal extremities with virocyte or Reed-Sternberg–like cells—it described the same entity of histologic features. The reported histologic similarities included numerous inflammatory cells (plasma cells, granulocytes, eosinophils, and lymphocytes), fibrosis, and scattered, large, bizarre tumor cells resembling Reed-Sternberg–like cells in an abundant myxoid extracellular matrix. Clinically, it is described in all age groups (4-91 yrs of age), occurs approximately equally among males and females, and commonly presents as a painless subcutaneous mass located in the distal extremities. In 2002, Jurcic et al reported 3 cases not located in the acral extremities, suggesting that the term “acral” was misleading when describing the tumor.

Refractory oral ulcers with multiple immunoglobulin G/immunoglobulin A autoantibodies without skin lesions

2010-04-01

To the Editor: Current molecular diagnostics have characterized many new autoimmune bullous diseases that traditional descriptive dermatology would not have been able to define. Herein we report a case of refractory oral ulcers with immunoblots that were confusing, causing difficulty in making a definitive diagnosis.

Acquired combined nutritional deficiency presenting as psoriasiform dermatitis

Diana Bolotin, Mark I. Racz, Vesna Petronic-Rosic, Aisha Sethi — 2010-04-01

To the Editor: Nutritional deficiency, a prevalent problem worldwide, remains rare in developed countries. In the United States, acquired nutritional deficiencies have been reported in patients with anorexia nervosa, malabsorption syndromes, those on long-term parenteral nutrition, and patients with food allergies. Given the significant morbidity and sometimes mortality associated with certain nutritional deficiencies, their prompt recognition, diagnosis, and treatment by clinicians is of great importance. Many nutritional deficiencies have classic cutaneous presentations that are valuable clinical diagnostic tools. However, combined nutritional deficiencies often put forth a mixed clinical picture easily mistaken for another condition. There is a paucity of reports of cutaneous presentations of combined nutritional deficiency in dark-skinned patients and of the expected time course of resolution with resupplementation. Here we report a case of multiple nutritional deficiencies in an African American female that presented both clinically and histologically as psoriasis but resolved completely with nutritional supplementation alone.

Phenytoin-induced acute generalized exanthemous pustulosis

Nasir Aziz, Samantha Toerge, Thomas Nigra — 2010-04-01

To the Editor: A 57-year-old African American male with a history of a seizure disorder caused by a traumatic head injury presented to the emergency department with a recent onset of multiple pustular lesions that started on his face and spread to his trunk and upper extremities. He had presented to the same emergency department 5 days earlier in status epilepticus. He was treated with 1 g phenytoin for the first time in addition to increased doses of his other medicines (lorazepam and levetiracetam). His seizure resolved and he was discharged 2 days later on increased doses of levetiracetam and valproic acid.

CD34+ connective tissue nevi: Are they unusual?

Kejal R. Shah, Michael J. Wells, Cloyce L. Stetson — 2010-04-01

To the Editor: A 1-year-old white male with a 6-month history of “raised bumps” overlying the dorsal surface of his neck was brought to our dermatology clinic for evaluation. An agminated patch of white papules was identified on the suboccipital neck (). Nuchal ultrasound was unremarkable. A 3-mm punch biopsy demonstrated spindle cell proliferation within the papillary dermis, without significant atypia (, A). Vascularity was slightly increased. The overlying epidermis was unremarkable. Laboratory tests for Ulex europaeus, S-100, CD68, muscle-specific actin, and smooth muscle actin were negative. The spindle cells and visualized vascular structures stained strongly positive for CD34 (, B). After a thorough Web-based literature search, we were unable to find any reports of CD34+ staining with connective tissue nevus (CTN), but we decided that the final pathologic diagnosis was most consistent with this diagnosis. In lieu of repeat biopsy or excision, the mother opted for a reevaluation in 1 year. The patient had no other medical history, family history, or clinical findings suggestive or suspicious for the diagnosis of tuberous sclerosis.

Pantheon der Dermatologie. Herausragende historische Personlichkeiten

Robert Goltz — 2010-04-01

The Pantheon in Rome survives today as one of the triumphs of Western architecture. It was erected between 120 and 124 AD by the Emperor Hadrian as a temple dedicated to the multiple gods of Rome. An eighteenth century depiction of it, in masterful perspective, by Giovanni Paolo Panini, now in the National Gallery of Art in Washington, DC graces the cover of this unique tribute to the “deities” of dermatology. It is fittingly entitled Pantheon der Dermatologie.

Iotaderma #195

Robert I. Rudolph — 2010-04-01

March iotaderma (#194)

Robert I. Rudolph — 2010-04-01

Editorial Board

2010-04-01

Information for Readers

2010-04-01

Instructions for Category 1 CME Credit

2010-04-01

Dermatology Calendar

2010-04-01

Journal of the American Academy of Dermatology

Urticarial lesions: If not urticaria, what else? The differential diagnosis of urticaria: Part I. Cutaneous diseases

Answers to CME examination

CME examination

Urticarial lesions: If not urticaria, what else? The differential diagnosis of urticaria: Part II. Systemic diseases

CME examination

Answers to CME examination

American Board of Dermatology Examination Dates

Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: Results of two placebo-controlled studies of daily application to the face and balding scalp for two 3-week cycles

Volunteers Needed

Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: Results of two placebo-controlled studies of daily application to the face and balding scalp for two 2-week cycles

Low rates of clinical recurrence after biopsy of benign to moderately dysplastic melanocytic nevi

Dermatoscopy of pigmented Bowen's disease

A 20-year analysis of previous and emerging allergens that elicit photoallergic contact dermatitis

Online Images in Dermatology Will Return Soon

Orofacial granulomatosis: Clinical features and long-term outcome of therapy

Platelet activation in patients with psoriasis: Increased plasma levels of platelet-derived microparticles and soluble P-selectin

Midline/paramedian longitudinal matrix excision with flap reconstruction: Alternative surgical techniques for evaluation of longitudinal melanonychia

Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser

Pyoderma gangrenosum: A review and update on new therapies

Treatment of erythrodermic psoriasis: From the medical board of the National Psoriasis Foundation

Antioxidants and their chemopreventive properties in dermatology

Erratum

Change of Address

Periorbital mucinosis: A variant of cutaneous lupus erythematosus?

Bisphosphonate-related osteonecrosis of the jaw presenting as a cutaneous dental sinus tract: A case report and review of the literature

Coexistent Kaposi sarcoma, cryptococcosis, and Mycobacterium avium intracellulare in a solitary cutaneous nodule in a patient with AIDS: Report of a case and literature review

A case of lymphoepithelioma-like carcinoma of the skin associated with Epstein–Barr virus infection

Comparison of advertising strategies between the indoor tanning and tobacco industries

Systematic review of the safety of topical corticosteroids in pregnancy

Concern regarding the safety of tumor necrosis factor-alfa antagonists in pregnancy

Hidradenitis suppurativa markedly decreases quality of life and professional activity

The 3S technique: Another minimally invasive technique in the treatment of saphenous varicose veins

Sentinel node biopsy: Not the standard of care for melanoma

Narrowband ultraviolet B phototherapy influences serum folate levels in patients with vitiligo

Myxoinflammatory fibroblastic sarcoma on the thigh

Refractory oral ulcers with multiple immunoglobulin G/immunoglobulin A autoantibodies without skin lesions

Acquired combined nutritional deficiency presenting as psoriasiform dermatitis

Phenytoin-induced acute generalized exanthemous pustulosis

CD34+ connective tissue nevi: Are they unusual?

Pantheon der Dermatologie. Herausragende historische Personlichkeiten

Iotaderma #195

March iotaderma (#194)

Editorial Board

Table of Contents

Information for Readers

Instructions for Category 1 CME Credit

Dermatology Calendar