Journal of the American Academy of Dermatology

Solar cheilosis: An ominous precursor: Part I. Diagnostic insights

Yuri T. Jadotte, Robert A. Schwartz — 2012-02-01

Squamous cell carcinoma (SCC) of the lower lip is a deadly nonmelanoma skin cancer. Its precursor, a distinctive cutaneous neoplasia analogous to cervical dysplasia, is known by the confusing term actinic cheilitis. Solar cheilosis (SC) is a more appropriate designation. It represents incipient SCC in situ. SC is widely recognized as an ultraviolet light–induced precancer of the lower lip that is typically seen in light-skinned individuals and others with poorly pigmented lower lips. Lip SCC is one of the most common malignancies of the oral cavity. SCC is much more likely to metastasize from the lip than cutaneous surfaces, with a 5-year overall survival rate of less than 75%. SC results from long-term exposure to ultraviolet radiation. The occurrence of SC is dose-dependent and is influenced by the patient’s solar exposure, age, genetic predisposition, geographic latitude of residence, occupation, leisure activities, and use of lip protective agents. Molecular abnormalities of SC are similar to those of actinic keratosis and facilitate the evolution to SCC. A high degree of clinical suspicion should be maintained, given the malignant nature of this condition. Ulceration and nodularity often indicate progression to SCC. We performed a Medline and Google Scholar search for all articles related to actinic cheilitis, actinic cheilosis, SC, actinic keratosis, solar keratosis, premalignant oral disease, and lip SCC, and have also evaluated many other articles and book chapters. One hundred forty-two peer-reviewed articles were identified as being of particular value. Pertinent facts were selected and analyzed.

CME examination

2012-02-01

Answers to CME examination

2012-02-01

Change of Address

2012-02-01

Solar cheilosis: An ominous precursor: Part II. Therapeutic perspectives

Yuri T. Jadotte, Robert A. Schwartz — 2012-02-01

The differential diagnosis of SC includes malignant, premalignant, metastatic, inflammatory, and eczematoid disorders, along with photodermatoses and a few rare but important disorders of the lower lip. Current treatment options include topical, ablative, and surgical therapies. Several clinical challenges are also addressed, including the issue of obtaining a high-yield diagnostic biopsy specimen while minimizing patient morbidity, field-directed treatment for SC, and strategies for combination therapy.

CME examination

2012-02-01

Answers to CME examination

2012-02-01

American Board of Dermatology Examination Dates

2012-02-01

Systematic skin cancer screening in Northern Germany

2011-11-10

Background: The incidence of skin cancer is increasing worldwide. For decades, opportunistic melanoma screening has been carried out to respond to this burden. However, despite potential positive effects such as reduced morbidity and mortality, there is still a lack of evidence for feasibility and effectiveness of organized skin cancer screening.Objective: The main aim of the project was to evaluate the feasibility of systematic skin cancer screening.Methods: In 2003, the Association of Dermatological Prevention was contracted to implement the population-based SCREEN project (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) in the German state of Schleswig-Holstein. A two-step program addressing malignant melanoma and nonmelanocytic skin cancer was implemented. Citizens (aged ≥20 years) with statutory health insurance were eligible for a standardized whole-body examination during the 12-month study period. Cancer registry and mortality data were used to assess first effects.Results: Of 1.88 million eligible citizens, 360,288 participated in SCREEN. The overall population-based participation rate was 19%. A total of 3103 malignant skin tumors were found. On the population level, invasive melanoma incidence increased by 34% during SCREEN. Five years after SCREEN a substantial decrease in melanoma mortality was seen (men: observed 0.79/100,000 and expected 2.00/100,000; women: observed 0.66/100,000 and expected 1.30/100,000).Limitations: Because of political reasons (resistance as well as lack of support from major German health care stakeholders), it was not possible to conduct a randomized controlled trial.Conclusions: The project showed that large-scale systematic skin cancer screening is feasible and has the potential to reduce skin cancer burden, including mortality. Based on the results of SCREEN, a national statutory skin cancer early detection program was implemented in Germany in 2008.

Total body skin examination for skin cancer screening in patients with focused symptoms

2011-07-15

Background: The value of total body skin examination (TBSE) for skin cancer screening is controversial.Objective: We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE.Methods: In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE.Results: We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas.Limitations: The impact of TBSE on skin cancer mortality was not evaluated.Conclusions: TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

Prevalence of self-report photosensitivity in cutaneous lupus erythematosus

2011-07-11

Background: Little is known about the prevalence of self-reported photosensitivity (PS) and its effects on quality of life in a US cutaneous lupus population.Objective: We sought to determine the prevalence of self-reported PS among a cutaneous lupus population and to examine its impact on quality of life.Methods: A total of 169 patients with lupus were interviewed about PS symptoms and completed the modified Skindex-29+3, a quality-of-life survey. A complete skin examination was conducted and the Cutaneous Lupus Erythematosus Disease Area and Severity Index was completed.Results: In all, 68% of patients reported some symptoms of PS. The PS group (those who reported a history of and current PS) scored worse on PS-related items of the modified Skindex-29+3 and had higher cutaneous disease activity as determined by the Cutaneous Lupus Erythematosus Disease Area and Severity Index. Patients with PS had worse symptoms and emotions and experienced significant functional impairments compared with patients who had cutaneous lupus without PS.Limitations: This study was done at a single referral center.Conclusions: Self-reported PS is very common among patients with cutaneous lupus and is associated with significant impairments related to symptoms, emotions, and daily functioning.

Positive patch test reactions in older individuals: Retrospective analysis from the North American Contact Dermatitis Group, 1994-2008

2011-05-20

Background: Relatively little is known about the epidemiology of allergic contact dermatitis in older individuals.Objectives: We sought to determine the frequency of positive and clinically relevant patch test reactions in older individuals (≥65 years old) referred for patch testing, and to compare these results with those of adults (≤64-19 years) and children (<18 years).Design: This was a retrospective cross-sectional analysis of North American Contact Dermatitis Group data from 1994 to 2008.Results: A total of 31,942 patients (older n = 5306; adults n = 25,028; children n = 1608) were patch tested. The overall frequency of at least one allergic reaction in older individuals was 67.3% as compared with 66.9% for adults (P = .5938) and 47% for children (P = .0011). Reaction rates that were statistically higher in older individuals as compared with both adults and children included: Myroxylon pereirae, fragrance mix I, quaternium-15, formaldehyde, imidazolidinyl urea, diazolidinyl urea, neomycin, bacitracin, methyldibromo glutaronitrile, methyldibromo glutaronitrile/phenoxyethanol, ethyleneurea melamine formaldehyde mix, and carba mix (P values < .0004). Patch test reaction rates that were significantly lower in older individuals than both comparison groups included: nickel, thimerosal, and cobalt (P values < .0001).Limitations: Referral population was a limitation.Conclusions: Older individuals were more likely to have at least one positive patch test reaction as compared with children, but had similar rates to adults. The frequency of positive reactions to specific allergens differed by age group, most likely as a result of exposures.

Long-term efficacy and safety of adalimumab in patients with moderate to severe psoriasis treated continuously over 3 years: Results from an open-label extension study for patients from REVEAL

Kenneth Gordon, Kim Papp, Yves Poulin, Yihua Gu, Stephen Rozzo, Eric H. Sasso — 2011-07-15

Background: REVEAL was a 52-week phase III trial of adalimumab therapy for moderate to severe chronic plaque psoriasis. Patients from REVEAL could enter an open-label extension trial to receive adalimumab for approximately 3 years of total therapy.Objective: We sought to determine long-term efficacy and safety of continuous adalimumab therapy for patients from REVEAL.Methods: Efficacy and safety over greater than 3 years of treatment were analyzed for 4 groups of patients from REVEAL. Patients who received adalimumab continuously from baseline were grouped by their responses in REVEAL: (1) greater than or equal to 75% improvement in Psoriasis Area and Severity Index (PASI) score (PASI 75) at weeks 16 and 33 (sustained responders); (2) less than PASI 75 at week 16; and (3) greater than or equal to PASI 75 at week 16 with 50% to less than 75% improvement in PASI score at week 33. Results were also analyzed for patients who began adalimumab after 16 weeks of placebo therapy.Results: For patients with sustained PASI 75 responses during REVEAL, efficacy was generally well maintained over 3 years, with 75%/90%/100% improvement in PASI score response rates (last observation carried forward) of 83%/59%/33% after 100 weeks and 76%/50%/31% after 160 weeks of continuous therapy. Some patients with less than PASI 75 responses in REVEAL also achieved long-term PASI 75 responses. Efficacy in the placebo/adalimumab group was consistent with the ensemble of results from the other 3 groups. Adverse event rates were consistent with those during REVEAL.Limitations: The REVEAL study design prevented analyzing all patients from the adalimumab arm as one long-term cohort.Conclusion: Adalimumab efficacy was well maintained over more than 3 years of continuous therapy for patients with sustained initial PASI 75 responses. Maintenance was best at the PASI 100 level.

Psoriasis and cardiovascular risk factors: A case-control study on inpatients comparing psoriasis to dermatitis

Jonathan Shapiro, Arnon David Cohen, Dahlia Weitzman, Roy Tal, Michael David — 2011-07-11

Background: Previous reports demonstrated an association between psoriasis and cardiovascular disease (CVD) risk factors. However, most of these studies were based on computerized databases of outpatient clinics, which, because of International Classification of Diseases, Ninth Revision coding issues, require validation of the diagnosis of psoriasis.Objective: We sought to study associations between psoriasis and CVD risk factors among psoriatic inpatients compared to inpatients with dermatitis.Methods: A case-control study was performed using computerized medical databases from the Department of Dermatology at Rabin Medical Center in Israel. Inpatients given the diagnosis of psoriasis were compared with inpatients given the diagnosis of forms of dermatitis for the prevalence of smoking, obesity, diabetes, hypertension, hyperlipidemia, and CVD. Logistic regression models were used for multivariate analyses.Results: The study included 1079 inpatients with psoriasis and 1079 age- and gender-matched inpatients with dermatitis (control patients). A multivariate logistic regression model demonstrated that psoriasis is an independent risk factor for diabetes (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.17–1.75), hypertension (OR 1.31; 95% CI 1.09–1.58), obesity (OR 1.32; 95% CI 0.99–1.76), and smoking (OR 1.38; 95% CI 1.10–1.73). Development of CVD was not significantly associated with psoriasis when correcting for diabetes, obesity, and hypertension.Limitations: Our study group was composed of inpatients only, which may be biased toward more elderly patients with severe psoriasis who may have consumed systemic treatment including immunosuppressants.Conclusions: Our study supports previous reports of an association between psoriasis and CVD risk factors, suggesting that the inflammatory process in psoriasis, but not in dermatitis, may have a systemic impact resulting in development of CVD risk factors.

Familial multiple discoid fibromas: A look-alike of Birt-Hogg-Dubé syndrome not linked to the FLCN locus

2011-07-27

Background: Previously, we proposed that familial multiple trichodiscomas (OMIM 190340) is distinct from Birt-Hogg-Dubé syndrome (BHD) (OMIM #135150). BHD is characterized by multiple fibrofolliculomas/trichodiscomas, lung cysts, pneumothorax, and renal cell cancer. Germline FLCN mutations can be detected in most but not all BHD families.Objective: We sought to evaluate familial multiple trichodiscomas at a clinical and genetic level. We now renamed this condition “familial multiple discoid fibromas” (FMDF) to emphasize the distinction from BHD.Methods: In 8 additional families with an autosomal dominant pattern of multiple discoid fibromas we assessed the clinical findings and the histopathological features of skin lesions. FLCN germline mutation analysis was completed in 7 families. In two of these families segregation analysis was performed using polymorphic DNA markers in and around the FLCN locus.Results: The clinical findings in FMDF are different from those in BHD with early onset of skin lesions, prominent involvement of the pinnae, and discoid fibromas without the follicular epithelial component characteristic of the fibrofolliculoma/trichodiscoma spectrum of BHD. In addition, there were no evident pulmonary or renal complications. In none of the families were pathogenic FLCN germline mutations identified. Using segregation analysis we could exclude involvement of the FLCN locus in the two kindreds tested.Limitations: The prevalence of FMDF is presently unknown. The underlying gene defect has not yet been identified.Conclusions: FMDF is clinically distinct from BHD and is not linked to the FLCN locus.

The efficacy of trimethoprim in wound healing of patients with epidermolysis bullosa: A feasibility trial

2011-12-08

Background: There are no systemic therapies known to facilitate wound healing in patients with recessive dystrophic epidermolysis bullosa (RDEB).Objectives: We sought to assess the feasibility of a trial to examine the efficacy of trimethoprim (TMP) in healing chronic wounds in patients with RDEB and to examine the effect of TMP on lesion counts, quality of life, and emergence of antibiotic resistance.Methods: We conducted a feasibility study using a prospective, randomized, double-blinded, placebo-controlled, crossover design. The study took place between October 2006 and September 2007 in the epidermolysis bullosa clinic at the Hospital for Sick Children in Toronto, Ontario, Canada. Liquid TMP or placebo was given orally or via gastrostomy tube in two divided doses for 2 months; the main outcome measure was a decrease in surface area of selected chronic wounds.Results: Ten subjects with RDEB were enrolled in the study; 7 completed both study arms (4 male, 3 female). Age at enrollment was 14 ± 5.4 years. Although all patients showed improved wound healing on TMP, the crossover analysis, TMP versus placebo, approached but did not reach statistical significance (P = .08). While receiving TMP, 6 of 7 patients had more than 50% reduction in chronic wound surface area; while receiving placebo, 2 of 6 patients had more than 50% reduction in wound surface area (P = .03). Secondary outcome measures did not achieve statistical significance.Limitations: Small sample size is a limitation.Conclusions: This proof-of-concept study demonstrates the potential efficacy of TMP in improving wound healing in RDEB, and provides useful information for further prospective studies.

Optimal tattoo removal in a single laser session based on the method of repeated exposures

Theodora Kossida, Dimitrios Rigopoulos, Andreas Katsambas, R. Rox Anderson — 2011-10-31

Background: Unwanted tattoos are treated with Q-switched lasers. Despite a series of treatments, efficacy is limited.Objective: We compared a single Q-switched laser treatment pass with 4 treatment passes separated by 20 minutes.Methods: Eighteen tattoos on 12 adults were divided in half and randomized. One half received a single treatment pass (the “conventional” method) with a Q-switched alexandrite laser (5.5 J/cm2, 755 nm, 100-nanosecond pulse duration, 3-mm spot size), and the other half received 4 treatment passes with an interval of 20 minutes between passes (the “R20” method). Tattoo lightening was compared 3 months later, by blinded evaluation of photographs. Biopsy specimens obtained before and immediately after treatment on both halves were also compared in blinded fashion.Results: Immediate whitening reaction occurred on the first treatment pass, with little or no whitening on subsequent passes. Three months later, treatment with the R20 method was much more effective than conventional single-pass laser treatment (P <.01; all tattoos favored the R20 method). Despite greater epidermal injury with the R20 method, neither method caused adverse events or scarring. Light microscopy showed greater dispersion of tattoo ink with the R20 method.Limitations: This prospective study involved a small number of subjects.Conclusions: The R20 method is much more effective than conventional laser tattoo treatment, removing most tattoos in a single treatment session. New laser device technology is not required to practice this method.

Clinicopathological features and prognostic significance of CXCL12 in blastic plasmacytoid dendritic cell neoplasm

2011-08-12

Background: Blastic plasmacytoid dendritic cell neoplasm (BPDC) is a rare hematologic neoplasm, which almost always involves the skin and shows poor prognosis.Objective: The aim of our study was to enhance BPDC diagnosis and indications for prognosis.Methods: This study involved 26 patients with BPDC. To investigate the histogenesis of BPDC, we reviewed the clinical features and stained markers of various hematopoietic lineages, chemokines, and their receptors.Results: Bone-marrow infiltration was detected in 13 of the 19 cases examined and leukemic changes in 18. Complete remission was achieved in 14 cases, but more than half of the patients showed recurrence within a short time, and 14 patients died of the disease after 1 to 25 months (mean 8.5 months). Positivity for CD123 was detected in 18 of 24 cases and for T-cell leukemia 1 in 18 of 22 cases. Of the chemokines and their receptors, 8 of 15 skin biopsy specimens proved to be positive for CXCL12. Leukemic change subsequent to skin lesions occurred in 7 of 8 CXCL12-positive cases (87.5%) and in 3 of 6 CXCL12-negative cases (50%). Seven of the 8 CXCL12-positive patients (87.5%) and two of the 6 CXCL12-negative patients (33.3%) have died, whereas one of 8 CXCL12-positive patients (12.5%) and 4 of 6 CXCL12-negative patients (66.7%) remain alive.Limitations: The number of patients was limited.Conclusions: We speculate that the presence of CXCL12-positive cells in the skin may be associated with leukemic change and a poor prognosis.

Generalized verrucosis: A review of the associated diseases, evaluation, and treatments

2011-05-16

Generalized verrucosis has been described in the past as synonymous with epidermodysplasia verruciformis. It has been shown, however, that epidermodysplasia verruciformis and other genetic or immunodeficiency diseases are just a subset of diffuse infections with human papillomavirus termed “generalized verrucosis.” This article defines generalized verrucosis and distinct diseases associated with generalized warts. The indications for histopathologic testing, human papillomavirus typing, and other laboratory analyses and potential treatment options are discussed.

Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy

2011-05-23

Introduction: Intravenous immunoglobulin (IVIG) is used to treat many inflammatory and autoimmune disorders and although generally well tolerated, cutaneous side effects occur.Objective: We reviewed reports of pompholyx and eczematous reactions associated with IVIG.Methods: A literature search was performed using the PubMed and MEDLINE databases with the search terms “intravenous immunoglobulin pompholyx,” “intravenous immunoglobulin eczema,” “intravenous immunoglobulin cutaneous adverse effects,” “intravenous immunoglobulin cutaneous effects,” “intravenous immunoglobulin skin effects,” and “intravenous immunoglobulin adverse effects.” Relevant English-language articles or articles in other languages cited in English-language articles were included.Results: We identified 64 cases of eczematous reactions associated with IVIG therapy, including a patient treated on our inpatient consult service. In reported cases, the majority of patients (62.5%) had pompholyx alone or a combination of pompholyx on the hands or feet and two or fewer additional body surfaces involved. The majority of reported cases (75%) experienced the eczematous reaction after their first IVIG treatment. Neurologic conditions were the most common (85.9%) diseases for which IVIG was used. Most patients responded well to topical steroids or did not require treatment.Limitations: Some reported cases had insufficient descriptions to be included in this review. A literature review may underestimate the frequency of eczematous reactions to IVIG because these reactions are often limited and may not be reported.Conclusions: With the use of IVIG increasing, it is important for dermatologists to recognize this cutaneous side effect of IVIG.

Biopharmaceuticals and biosimilars in psoriasis: What the dermatologist needs to know

2012-02-01

The entry of biosimilar forms of biopharmaceutical therapies for the treatment of psoriasis and other immune-mediated disorders has provoked considerable interest. Although dermatologists are accustomed to the use of a wide range of generic topical agents, recognition of key differences between original agent (ie, the name brand) and the generic or biosimilar agent is necessary to support optimal therapy management and patient care. In this review we have summarized the current state of the art related to the impending introduction of biosimilars into dermatology. Biosimilars represent important interventions that are less expensive and hence offer the potential to deliver benefit to large numbers of patients who may not currently be able to access these therapies. But the development of biosimilars is not equivalent to that of small molecule generic therapies because of differences in molecular structure and processes of manufacture. The planned regulatory guidelines and path to approval may not encompass all of these potentially important differences and this may have clinical relevance to the prescriber and patient. Consequently, we have identified a series of key issues that should be considered to support the full potential of biosimilars for the treatment of psoriasis; ie, that of increased access to appropriate therapy for the psoriasis population worldwide.

Limitations of the “spaghetti technique”

Navid Bouzari, Emily J. Fisher, Mollie A. MacCormack, Suzanne Olbricht — 2012-02-01

To the Editor: We read with great interest the recent article by Gaudy-Marqueste et al entitled “The ‘‘spaghetti technique’’: An alternative to Mohs surgery or staged surgery for problematic lentiginous melanoma (lentigo maligna and acral lentiginous melanoma)” in the January 2011 edition of the Journal. The authors introduced a two-phase procedure (spaghetti technique), which seems to be a modification of the “square technique” described in 1997 by Johnson et al. We agree with the authors that the spaghetti technique provides a comprehensive longitudinal en face dermatopathologic control of the periphery. However, in our opinion, the technique has some disadvantages. The major drawback of the spaghetti technique is that the central tumor is not excised until the time of closure, so an unsuspected invasive melanoma would not be identified until after closure is complete. In a recent review of 10 studies on histologically proven lentigo maligna and melanoma in-situ lesions, Dawn, Dawn, and Miller determined that 23% have an invasive melanoma upon re-excision. When an invasive melanoma is found, the surgical margin is generally determined according to the National Comprehensive Cancer Network (NCCN) guidelines on the basis of the tumor depth, regardless of the histology of the “spaghetti” sections. This may lead to a second surgical procedure if the margins of the spaghetti technique are less than the depth-appropriate margins. In addition, some surgical oncologists prefer to perform wide excision at the same time as nodal evaluation.

Segmentally grouped melanocytic nevi and melanoma risk

Daniele Torchia — 2012-02-01

To the Editor: In the June 2011 issue of the JAAD, Ly et al reported a 4-case series on malignant melanoma (MM) arising on speckled lentiginous nevus (SLN). It is my opinion that none of those cases can be classified as SLN because by definition SLN, either of the macular or papular type, is characterized by a homogeneous hyperpigmented background which defines the size of the lesion and is virtually indistinguishable from café-au-lait spots (CALs) as of color and histologic features. Instead, in all 4 cases, lentigines (and often CALs) were present in a block-like segmental pattern, and a hyperpigmented background was evidently absent as it would have made invisible the lentigines and, mostly, CALs. Taken all together, these features are instead pathognomonic for partial unilateral lentiginosis (or, more appropriately, segmental lentiginosis [SL]). The presence of papular melanocytic nevi within the lesions is not surprising and can be reasonably attributed to evolution of lentigines. An increasing number of lentigines over time is a well-described phenomenon in SL as well.

Reply

Lena Ly, Ingrid Winship, John William Kelly — 2012-02-01

To the Editor: We would disagree with the primary argument put forward by Torchia in response to our article “Melanoma(s) arising in large segmental speckled lentiginous nevi (SLN): A case series,” which disputes the diagnosis of SLN in all 4 cases described.

Long-term prognosis of vitiligo patients on narrowband UVB phototherapy

Kelly K. Park, Jenny E. Murase, John Koo — 2012-02-01

To the Editor: We read with interest the CME article on vitiligo that mentioned the paucity of long-term follow-up data of narrowband ultraviolet B (NB-UVB) therapy in vitiligo. Although there are no established treatment caps for NB-UVB, the suggested limit for skin types I-III is arbitrarily set at 200 treatments. While there is no set limit for skin types IV-VI, the recommendation for number of treatments should be based on clinician discretion and patient consent. We have observed that long-term NB-UVB in vitiligo patients is safe. This is important because these patients often require more than 12 to 24 months of treatment for repigmentation.

Randomized study of topical tacrolimus ointment as possible treatment for resistant idiopathic pruritus ani

Erwin Suys — 2012-02-01

To the Editor: Pruritus ani (PA) is a common and embarrassing proctologic condition, which can be difficult to treat if there are no obvious predisposing factors. There is little scientific evidence concerning the treatment of idiopathic PA. Randomized controlled studies have been published for both 1% hydrocortisone ointment (symptom reduction in 68% of patients after 2 weeks’ treatment compared with placebo) and capsaicin 0.006% (70% with relieved itching compared with 2% with placebo after 4 weeks 3 times daily). Intradermal injection of methylene blue is frequently reported, but no randomized studies have been done. Prolonged topical steroid use may provoke skin atrophy. Topical tacrolimus is proposed as an alternative treatment for inflammatory skin diseases in thin skin areas.

Infliximab as a steroid-sparing agent in refractory cutaneous sarcoidosis: Single-center retrospective study of 9 patients

2012-02-01

To the Editor: Therapeutic options for cutaneous sarcoidosis are limited. Several reports of successful treatment of cutaneous sarcoidosis with anti-tumor necrosis factor have been published. We aimed to evaluate our experience with the use of infliximab in refractory cutaneous sarcoidosis.

Grover disease may result from the impairment of keratinocytic cholinergic receptors

David Paslin — 2012-02-01

To the Editor: Grover disease is an eruption of intraepidermal acantholysis presenting as crusted reddened papules; it is usually found on the trunk of middle aged patients, with a male to female ratio of 2:1. The disease may be transient or persistent. Although the onset of Grover disease often appears to be spontaneous, the expression of Grover disease has been associated with a multitude of factors, including sun exposure, winter time, interleukin-4 administration, heat or sweat, ionizing radiation, psoralen plus ultraviolet A light phototherapy, chemotherapy, and chronic renal failure. Causation has not been established.

Phaeohyphomycosis caused by Phaeoacremonium species in a patient taking infliximab

Jason D. Mazzurco, James Ramirez, David P. Fivenson — 2012-02-01

To the Editor: We report a 74-year-old man with a history of severe rheumatoid arthritis treated with infliximab who presented with a slowly enlarging nodule on his posterior left leg. The lesion began as a small red bump approximately 1 month after being stuck with a thorn of a pyracantha bush. The bump grew in size over 4 months and was unresponsive to multiple oral antibiotics. Bacterial cultures were negative. The patient did not complain of any systemic symptoms. Physical examination showed a 1.5- × 4-cm violaceous scaling and crusted nodule on the posterior aspect of his left leg (). No lymphadenopathy was present.

Use of a hydrocolloid dressing to aid in the closure of surgical wounds in patients with fragile skin

Jason D. Mazzurco, Kent Jerome Krach — 2012-02-01

To the Editor: When repairing surgical defects in patients with thin, fragile skin, it can sometimes be difficult to suture wounds without tearing through cutaneous layers, particularly for distal extremity defects in elderly patients with extreme photodamage. Additional comorbidities, such as prolonged systemic steroid use, can further complicate closures in these patients. In these extreme cases the dermis is too thin to anchor deep sutures, and attempts with full-thickness superficial sutures result in skin tearing if the wound is under tension. This necessitates the use of other techniques or devices to aid in the closure of these surgical defects.

JAAD Grand Rounds quiz∗ A 46-year-old man with agminated papules on the buttock

Marsha D. Mitchum, Erin G. Adams, Katherine Z. Holcomb — 2012-02-01

Instructions: In answering each question, refer to the specific directions provided. Because it is often necessary to provide information occurring later in a series that gives away answers to earlier questions, please answer the questions in each series in sequence.

A 40-year-old man with hyperkeratotic palms and soles

Joy D. Wisniewski, Rashid M. Rashid, Carolyn A. Bangert — 2012-02-01

A 40-year-old Hispanic man presented with thickened, fissured, and peeling palms and soles that had been present since childhood (). He was seen for a refill of his medication (acitretin 25 mg/day), which improved the symptoms.

Red, purple, and brown skin lesions in a 2-month-old boy

Jeffrey R. Smith, Mary M. Moore, Cloyce L. Stetson — 2012-02-01

A 2-month-old boy presented with a homogenous and reticulated erythematous patch involving the right side of his face, mainly in the distribution of cranial nerve V1/V2 (). This erythematous to purple reticulation continued over the right half of the anterior surface of the patient’s trunk, right leg, and most of the posterior surface of the trunk (). The right lower extremity, left middle back, and lower back extending to the sacrum had darker blue-brown patches (). All of these patches had been present since birth. No limb hypertrophy, atrophy, or length discrepancy was noted. The patient had previously been diagnosed with glaucoma of the right eye.

An infant with persistent bullous urticaria

Jeffrey Mailhot, Silvina Pugliese, Rujing Han, Karen Wiss — 2012-02-01

A 6-month-old male presents with persistent urticaria that has been present since 1 month of age and that began after starting a course of oral ranitidine. The physical examination reveals striking dermatographism and numerous wheals on his trunk and extremities, some with superimposed vesicles and bullae. The distribution of lesions coincides with areas of friction, rubbing, and/or scratching, and the skin appears otherwise normal. Radioallergosorbent testing is negative for common food allergens, a complete blood cell count is normal, and the serum tryptase level is 112 μg/L (normal range, 0.4-10.9 μg/L). At 10 months of age, he develops a cobblestoned, doughy pattern on his upper extremities and trunk (). A 3-mm punch biopsy specimen is obtained and is stained with hematoxylin–eosin and Leder stains (; inset, Leder stain).

Erosive plaques on the dorsal surfaces of the hands

2012-02-01

An otherwise healthy 58-year-old woman presents with a 10-day history of ulcers on the dorsal surfaces of both hands. The initial lesion, an expanding pustule, became bullous and erosive. She subsequently developed large bullous hemorrhagic plaques on both forearms. The patient denies systemic symptoms, oral or genital ulcers, sick contacts, recent travel, contact with chemicals, or new medications. The physical examination reveals large eroded exophytic erythematous plaques with overlying bullae on the dorsal surfaces of her hands and forearms (). An outside punch biopsy specimen is obtained and reveals a diffuse neutrophilic infiltrate throughout the dermis with focal vasculitis. Stains for fungi and bacteria are negative. A repeat biopsy is performed (). Based on clinical and histopathologic findings, the patient is diagnosed with neutrophilic dermatosis of the dorsal hands (NDDH), a rare entity included in a spectrum of conditions known as neutrophilic dermatoses (characterized by a predominantly neutrophilic inflammatory infiltrate). NDDH classically presents acutely as violaceous indurated plaques on the dorsal radial surfaces of the hands.

Assessment of the long-term safety and effectiveness of etanercept for the treatment of psoriasis in an adult population

2010-09-20

Background: Etanercept is well tolerated and effective in moderate to severe plaque psoriasis. However, effectiveness and safety data beyond 2.5 years have not been reported.Objective: We sought to assess the effectiveness and safety profile of up to 4 years of etanercept therapy in psoriasis.Methods: We analyzed prospective data from previous trials and open-label extensions, including 506 patients who initiated etanercept therapy in either of two phase III trials. Patients received etanercept, 25 mg twice weekly, 50 mg weekly, or 50 mg twice weekly, depending on which trial therapy was started. Dosage adjustments were allowed in open-label extensions, but no patients exceeded 50 mg twice weekly. Outcomes included change from baseline for the static Physician Global Assessment and Dermatology Life Quality Index scores. Exposure-adjusted adverse event (AE) rates were calculated.Results: In all, 75.9% (95% confidence interval 67.9-84.0) and 27.8% (95% confidence interval 19.3-36.2) maintained Dermatology Life Quality Index response (≥5-point improvement from baseline) and static Physician Global Assessment response (clear or almost clear) at 48 months, respectively. AE and serious AE rates were 243.5 and 7.8 events per 100 patient-years, respectively. No serious AE rates exceeded 1.0 event per 100 patient-years. Overall infection and serious infection rates were 96.9 and 0.9 events per 100 patient-years, respectively. No cases of tuberculosis or lymphoma were reported.Limitations: Effectiveness data were limited to static Physician Global Assessment and Dermatology Life Quality Index scores. Analysis of AE rates was limited to available comparator databases.Conclusion: Etanercept demonstrated sustained effectiveness and a favorable safety profile with no cumulative toxicity for up to 4 years, representing, to our knowledge, the longest published study on etanercept use in psoriasis to date.

In vivo reflectance confocal microscopy of extramammary Paget disease: Diagnostic evaluation and surgical management

Zhan-Yan Pan, Jun Liang, Qiao-An Zhang, Jing-Ran Lin, Zhi-Zhong Zheng — 2011-05-27

Background: Extramammary Paget disease (EMPD) is a diagnostic challenge. In vivo reflectance confocal microscopy (RCM) has been reported to be useful for in vivo skin tumor evaluation. It may also assist in the surgical management of EMPD lesions.Objective: We sought to describe confocal features of EMPD and correlate them with histopathologic findings. The potential of RCM to map the lesions for subsequent surgical management was also investigated.Methods: A total of 23 lesions from 14 recruited patients were evaluated by RCM and histopathologic examination. RCM was used to delineate preoperative surgical margins in two patients.Results: Erythematous, hyperpigmented, and hypopigmented lesions were evaluated by RCM and results were confirmed by histopathologic examination. Paget cells were observed throughout the epidermis. Typical Paget cells on RCM were characterized by a mild bright nucleus and dark cytoplasm, frequently twice the size of keratinocytes or larger. At the dermoepidermal junction, tumor nests were seen as dark glandular structures. A high density of dendritic cells was observed in pigmented lesions and a low density in erythematous lesions. Dilated vessels and inflammatory cells were seen in pigmented and erythematous lesions. Paget cells within the epidermis and nest structures at the dermoepidermal junction were seen in most lesions. These two features were useful for delineating the margins. Histologic examination corroborated the surgical margins found by RCM.Limitations: The sensitivity and specificity of these diagnostic features have not been fully studied, and differential diagnostic features require exploration.Conclusion: Features correlating well to histopathology are observed on the RCM of EMPD lesions. RCM may be used as an auxiliary diagnostic tool for the diagnosis and management of EMPD.

Cutaneous small-vessel vasculitis associated with solid organ malignancies: The Mayo Clinic experience, 1996 to 2009

Joshua O. Podjasek, David A. Wetter, Mark R. Pittelkow, David A. Wada — 2010-11-19

Background: Although rare, cutaneous small-vessel vasculitis (CSVV) secondary to solid organ malignancy has been documented.Objective: We sought to better understand the frequency, clinical course, therapeutic response, and outcome of CSVV associated with solid organ malignancy.Methods: We conducted a retrospective chart review of patients seen between 1996 and 2009 with diagnoses of biopsy-proven cutaneous leukocytoclastic vasculitis and solid organ malignancy separated by less than 12 months.Results: Of 17 patients (mean age, 66.5 years), 10 patients (59%) were male. CSVV occurred before (3 patients; 18%), concurrent with (3 patients; 18%), and after (11 patients; 65%) diagnosis of solid organ malignancy. The most common solid organ malignancy was of the lung (n = 4; 24%). Other associated cancers were breast (n = 3); prostate (n = 2); colon (n = 2); renal (n = 2); thyroid (n = 1); bladder (n = 1); gallbladder (n = 1); and peritoneal (n = 1). Three patients had cutaneous vasculitis in association with malignancy recurrence despite having no cutaneous vasculitis associated with their primary malignancy. Vasculitis remission with use of immunosuppressive agents alone occurred in 9 patients (53%). Eleven patients (65%) were alive at last follow-up (mean follow-up duration, 27 months).Limitations: This was a retrospective study with a relatively small number of patients.Conclusion: Solid organ malignancy should be considered as a possible cause of CSVV of unknown origin. In contrast to previous reports, our patients were more likely to respond to immunosuppressive therapies without treatment of the associated malignancy and to be alive at last follow-up.

The effects of adalimumab treatment and psoriasis severity on self-reported work productivity and activity impairment for patients with moderate to severe psoriasis

2011-05-26

Background: Psoriasis significantly impairs work productivity and daily activities.Objectives: We sought to examine the effects of adalimumab on psoriasis-related work productivity and activity impairment and associations between the impairment and psoriasis severity in patients with moderate to severe psoriasis.Methods: Data were from the first 16 weeks of the Randomized controlled EValuation of adalimumab Every other week dosing in moderate to severe psoriasis TriAL (REVEAL). Outcomes as measured by the Work Productivity and Activity Impairment Questionnaire for Psoriasis (WPAI-Psoriasis) included employment status, total work productivity impairment, and total activity impairment. Logistic regression and analyses of covariance were used to assess the effects of adalimumab and treatment response (≥75% improvement in Psoriasis Area and Severity Index responders) on WPAI-Psoriasis outcomes. Longitudinal generalized estimating equations and Pearson correlation coefficients were used to assess associations between WPAI outcomes and psoriasis severity.Results: Greater improvements in total work productivity impairment and total activity impairment were observed with adalimumab treatment versus placebo (15.5 and 11.1 percentage points, respectively; P < .001). Unemployment rate, total work productivity impairment, and total activity impairment were significantly associated with greater baseline psoriasis severity. Changes in WPAI outcomes were significantly correlated with greater psoriasis severity. The Dermatology Life Quality Index had stronger associations with changes in WPAI outcomes compared with clinical severity measures (Psoriasis Area and Severity Index and Physician Global Assessment).Limitations: REVEAL only included WPAI data for 16 weeks. Therefore, long-term impact of adalimumab treatment on productivity outcomes could not be assessed. In addition, information on occupational job title or industry was not collected and data were not adjusted for psoriatic arthritis.Conclusions: Adalimumab reduced psoriasis-related work productivity and activity impairment in patients with moderate to severe psoriasis.

Iotaderma #217

Robert I. Rudolph — 2012-02-01

January iotaderma (#216)

Robert I. Rudolph — 2012-02-01

Editorial Board

2012-02-01

Information for Readers

2012-02-01

Dermatology Calendar

2012-02-01

Journal of the American Academy of Dermatology

Solar cheilosis: An ominous precursor: Part I. Diagnostic insights

CME examination

Answers to CME examination

Change of Address

Solar cheilosis: An ominous precursor: Part II. Therapeutic perspectives

CME examination

Answers to CME examination

American Board of Dermatology Examination Dates

Systematic skin cancer screening in Northern Germany

Total body skin examination for skin cancer screening in patients with focused symptoms

Prevalence of self-report photosensitivity in cutaneous lupus erythematosus

Positive patch test reactions in older individuals: Retrospective analysis from the North American Contact Dermatitis Group, 1994-2008

Long-term efficacy and safety of adalimumab in patients with moderate to severe psoriasis treated continuously over 3 years: Results from an open-label extension study for patients from REVEAL

Psoriasis and cardiovascular risk factors: A case-control study on inpatients comparing psoriasis to dermatitis

Familial multiple discoid fibromas: A look-alike of Birt-Hogg-Dubé syndrome not linked to the FLCN locus

The efficacy of trimethoprim in wound healing of patients with epidermolysis bullosa: A feasibility trial

Optimal tattoo removal in a single laser session based on the method of repeated exposures

Clinicopathological features and prognostic significance of CXCL12 in blastic plasmacytoid dendritic cell neoplasm

Generalized verrucosis: A review of the associated diseases, evaluation, and treatments

Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy

Biopharmaceuticals and biosimilars in psoriasis: What the dermatologist needs to know

Limitations of the “spaghetti technique”

Segmentally grouped melanocytic nevi and melanoma risk

Reply

Long-term prognosis of vitiligo patients on narrowband UVB phototherapy

Randomized study of topical tacrolimus ointment as possible treatment for resistant idiopathic pruritus ani

Infliximab as a steroid-sparing agent in refractory cutaneous sarcoidosis: Single-center retrospective study of 9 patients

Grover disease may result from the impairment of keratinocytic cholinergic receptors

Phaeohyphomycosis caused by Phaeoacremonium species in a patient taking infliximab

Use of a hydrocolloid dressing to aid in the closure of surgical wounds in patients with fragile skin

JAAD Grand Rounds quiz∗ A 46-year-old man with agminated papules on the buttock

A 40-year-old man with hyperkeratotic palms and soles

Red, purple, and brown skin lesions in a 2-month-old boy

An infant with persistent bullous urticaria

Erosive plaques on the dorsal surfaces of the hands

Assessment of the long-term safety and effectiveness of etanercept for the treatment of psoriasis in an adult population

In vivo reflectance confocal microscopy of extramammary Paget disease: Diagnostic evaluation and surgical management

Cutaneous small-vessel vasculitis associated with solid organ malignancies: The Mayo Clinic experience, 1996 to 2009

The effects of adalimumab treatment and psoriasis severity on self-reported work productivity and activity impairment for patients with moderate to severe psoriasis

Iotaderma #217

January iotaderma (#216)

Editorial Board

Table of Contents

Information for Readers

Dermatology Calendar