Journal of the American Academy of Dermatology - Articles in Press

Comparison of advertising strategies between the indoor tanning and tobacco industries - Corrected Proof

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.

Atypical vascular lesion of the breast - Corrected Proof

Joshua Mandrell, Sheetal Mehta, Stacy McClure — 2010-02-08

Atypical vascular lesions (AVLs) are vascular proliferations that develop after surgery and radiation for breast carcinoma and may represent precursors to angiosarcoma. AVLs are not well-known entities and currently lack official prognostic factors and guidelines for surgical treatment. We report the case of a patient who developed an AVL, vascular type, 4 years after lumpectomy and radiation therapy for ductal carcinoma in situ of the breast. The patient underwent wide local excision with 1-cm margins with subsequent pathologic examination confirming complete excision of the residual atypical vascular proliferation. This case highlights the importance of close cutaneous surveillance in patients with a history of surgery and radiation for breast carcinoma, and a low threshold for biopsy. More studies are needed to further delineate the risk of AVLs progressing to angiosarcoma and to identify histologic features or immunophenotypic markers, which may be predictive of this risk. Furthermore, formal treatment recommendations for these enigmatic entities would be helpful.

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

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.

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 - Corrected Proof

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.

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 - Corrected Proof

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.

Systematic review of the safety of topical corticosteroids in pregnancy - Corrected Proof

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.

Folliculotropic mycosis fungoides: Clinicopathological features and outcome in a series of 20 cases - Corrected Proof

2010-01-18

Background: Folliculotropic mycosis fungoides (MF) is a rare variant of cutaneous T-cell lymphoma in which the neoplastic T lymphocytes display tropism for the follicular epithelium.Objectives: To better categorize this rare form of cutaneous T-cell lymphoma we evaluated the clinical, pathological, and immunophenotypic findings, and the response to therapy and course of the disease.Methods: Folliculotropic MF cases were selected from the registry of the Thematic Network of Cutaneous Lymphoma of Barcelona (Spain) from 1988 to 2007.Results: Twenty patients (11 male, 9 female) with a mean age of 54 years were included. Mean follow-up time was 43 months. The most common sites of involvement were the head and neck (80%), upper extremities, and thorax. Infiltrated plaques (55%), acneiform lesions (comedo-like and epidermal cysts) (45%), and follicular keratosis-pilaris–like lesions (45%) were the more prominent features. Histopathological findings included selective infiltration of the follicular epithelium by atypical lymphocytes in all cases. Mucinous degeneration of the follicular epithelium occurred in 60% of cases. Psoralen plus ultraviolet A therapy was the treatment of choice in the majority of patients, but these patients did not respond as well as patients with classic MF. Radiotherapy (local or total skin electron beam) was found to be the most effective treatment. A good response to bexarotene was seen in some patients.Limitation: This was a case series descriptive study.Conclusions: Folliculotropic MF is a rare but well-defined clinicopathological variant of MF. Although refractory to standard therapies used in classic MF, most of our patients showed only slow disease progression.

X-linked ichthyosis: An oculocutaneous genodermatosis - Corrected Proof

Neil Fernandes, Camila K. Janniger, Robert A. Schwartz — 2010-01-18

X-linked ichthyosis (XLI) is an X-linked recessive disorder of cutaneous keratinization with possible extracutaneous manifestations. It was first described as a distinct type of ichthyosis in 1965. XLI is caused by a deficiency in steroid sulfatase activity, which results in abnormal desquamation and a retention hyperkeratosis. XLI is usually evident during the first few weeks of life as polygonal, loosely adherent translucent scales in a generalized distribution that desquamate widely. These are quickly replaced by large, dark brown, tightly adherent scales occurring primarily symmetrically on the extensor surfaces and the side of the trunk. In addition, extracutaneous manifestations such as corneal opacities, cryptorchidism, and abnormalities related to contiguous gene syndromes may be observed. Diagnosis of XLI is usually made clinically, as the histopathology is nonspecific, but confirmation may be obtained through either biochemical or genetic analysis. Treatment should focus on cutaneous hydration, lubrication, and keratolysis and includes topical moisturizers and topical retinoids

Dermatoscopy of pigmented Bowen's disease - Corrected Proof

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.

Malignant melanoma transformation within a nevus of Ito - Corrected Proof

Sean R. Wise, Gregory Capra, Peter Martin, Donna Wallace, Charles Miller — 2010-01-14

The mongolian spot, nevus of Ota, and nevus of Ito are the most common morphologic forms of the dermal melanocytoses, a group of benign pigmented lesions histologically characterized by the presence of melanocytes within the dermis. Nevus of Ito is clinically distinct, presenting with unilateral, bluish gray, patchy discolorations in the skin within the distributions of the posterior supraclavicular and lateral cutaneous brachial nerves. Although all dermal melanocytoses are generally considered benign, rare cases of malignant transformation associated with nevus of Ota have been described. Only one case of malignant melanoma transformation in association with nevus of Ito has previously been reported. We present the second description of malignant melanoma transformation within a nevus of Ito and provide comment on the malignant potential of the dermal melanocytoses.

Efficacy and safety of mycophenolate mofetil for lichen planopilaris - Corrected Proof

2010-01-11

Background: Lichen planopilaris (LPP) is a chronic inflammatory disorder that causes permanent scalp hair loss and significant patient discomfort.Objectives: We sought to determine the efficacy and safety of mycophenolate mofetil (MMF) for treatment of LPP in patients who had failed prior topical, intralesional, or oral anti-inflammatory medications such as hydroxychloroquine or cyclosporine.Methods: We conducted a retrospective chart review of 16 adult patients with LPP treated with at least 6 months of MMF in an open-label, single-center study from 2003 to 2007. Subjective and objective end points were quantified using the LPP Activity Index (LPPAI) and scores before and after treatment were assessed using a paired t test. Adverse events were monitored.Results: Patients who completed treatment with MMF had significantly decreased signs and symptoms of active LPP despite having failed multiple prior therapies (P < .005). Five of 12 patients were complete responders (LPPAI score decreased>85%), 5 of 12 patients were partial responders (LPPAI score decreased 25%-85%), and two of 12 patients were treatment failures (LPPAI score decreased<25%). Four patients withdrew from the trial because of adverse events.Limitations: Retrospective analysis and small sample size were limitations.Conclusions: MMF was effective at reducing the signs and symptoms of active LPP in 83% of patients (10 of 12) who had failed multiple prior treatments after at least 6 months of treatment.

Human eyelid meibomian glands and tarsal muscle are recognized by autoantibodies from patients affected by a new variant of endemic pemphigus foliaceus in El-Bagre, Colombia, South America - Corrected Proof

2010-01-11

Background: Previously, we described a new variant of endemic pemphigus foliaceus (EPF) in Colombia, South America (El Bagre-EPF).Objective: Continuing our characterization of this variant of EPF, we now focus on one of our previously reported clinical findings: the presence of ocular lesions. These ocular lesions are seen in patients having extensive skin involvement, as measured by the Lund and Browder scale, which is generally used for patients with skin burns.Methods: We specifically searched for evidence of autoreactivity to various eyelid structures in these patients and correlated our immunologic data with the clinical findings. We performed indirect immunofluorescence studies using normal-appearing human eyelid skin from routine blepharoplasties as substrate tissue. We tested sera from 12 patients with El Bagre-EPF and ocular lesions, 5 patients with sporadic (nonendemic) pemphigus foliaceus, and 20 healthy control subjects (10 from the El Bagre-EPF endemic area and 10 from nonendemic areas). We used fluorescein isothiocyanate conjugated goat antiserum to human total IgG/IgA/IgM as a secondary antibody. In addition, we used fluorescein isothiocyanate conjugated antibodies to human fibrinogen, albumin, IgG, IgE, C1q, and C3, Texas Red (Rockland Immunochemicals, Inc, Gilbertsville, PA), Alexa Fluor 555, or Alexa Fluor 594 (Invitrogen, Carlsbad, CA). Ki-67 (a cell proliferation marker) was used to determine the cell proliferation rate, and nuclear counterstaining was performed with either 4′, 6-diamidino-2-phenylindole or Topro III (Invitrogen, Carlsbad, CA).Results: We observed autoreactivity to multiple eyelid structures, including meibomian glands and tarsal muscle bundles at different levels, and some areas of the epidermis and the dermis close to the isthmus of the eyelids. Tarsal plate autoreactivity was seen in 10 of 12 of the El Bagre-EPF sera and in one control with pemphigus erythematosus. Furthermore, immunoprecipitation using an eyelid sample as a substrate with 1 mmol/L of sodium orthovanodate showed autoreactivity to several antigens, including some of possible lipid origin.Limitations: The main limitation of this study is the fact that the antigen or antigens remain unknown.Conclusion: We identified for the first time to our knowledge autoantibodies to meibomian glands and tarsal muscle in El Bagre-EPF. Our findings suggest that the autoantibodies to the ocular structures cause the clinical and histopathological findings in the ocular lesions in El Bagre-EPF.

Hydroxychloroquine and lichen planopilaris: Efficacy and introduction of Lichen Planopilaris Activity Index scoring system - Corrected Proof

Charles Chiang, Deborah Sah, Bryan K. Cho, Blanca E. Ochoa, Vera H. Price — 2010-01-11

Background: Lichen planopilaris (LPP) and its variant frontal fibrosing alopecia (FFA) are primary lymphocytic cicatricial alopecias for which there is no evidence-based therapy.Objective: We assessed the efficacy of hydroxychloroquine in active LPP and FFA using the LPP Activity Index (LPPAI), a numeric score that allows quantification of the symptoms and signs of the condition for statistical comparison. In addition, we determined with the LPPAI if any improvement (reduction) in the numeric score pretreatment and posttreatment reached statistical significance.Methods: This was a retrospective, single-center chart review of 40 adult patients with LPP, FFA, or both who were treated with hydroxychloroquine for up to 12 months from 2004 to 2007 at the University of California, San Francisco Hair Center. Symptoms, signs, activity, and spreading were scored at each visit in the standardized cicatricial alopecia flow chart. A numeric score was assigned to these markers of disease activity and a numeric score was calculated at each visit.Results: There was significant reduction (P < .001) in the LPPAI at both 6 and 12 months. After 6 months, 69% had improved (reduced) symptoms and signs. At 12 months, 83% had improvement (reduction) in symptoms and signs.Limitations: Retrospective analysis and uncontrolled study are limitations.Conclusions: Hydroxychloroquine is effective in decreasing symptoms and signs in LPP and FFA as shown by significant reduction in the LPPAI in 69% and 83% of patients after 6 and 12 months of treatment, respectively.

Treatment of lichen planopilaris: Some progress, but a long way to go - Corrected Proof

Leonard C. Sperling, Jennifer V. Nguyen — 2010-01-11

For both patients and clinicians, lichen planopilaris (LPP) is a very challenging disease. Clinically and histologically, we observe active inflammation and disease progression, but our safe and simple anti-inflammatory medications often prove to be woefully inadequate. After topical and intralesional corticosteroids have been tried without good disease control, what are we to do?

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

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.

Expression of proliferative biomarkers in anal intraepithelial neoplasia of HIV-positive men - Corrected Proof

2009-12-14

Background: Anal intraepithelial neoplasia (AIN), a human papillomavirus (HPV)–associated precursor lesion of anal carcinoma, is highly prevalent among HIV-infected individuals, especially in men having sex with men (MSM). Early diagnosis and treatment of AIN might prevent development of anal cancer.Objectives: We aimed to evaluate the expression of 8 promising proliferative biomarkers in anal dysplasia and to compare the efficacy of these markers in diagnosing high-grade AIN.Methods: Immunohistochemical analysis of minichromosome maintenance proteins (MCM3, MCM4, MCM6, and MCM7), p21, Ki-67, p16, and proliferating cell nuclear antigen (PCNA) was performed in a total of 49 specimens of normal anal mucosa and high- and low-grade anal dysplasia. HPV typing for 36 high- and low-risk HPVs was performed, and high-risk HPV-DNA loads were determined by real-time polymerase chain reaction (PCR) for HPV-types 16, 18, 31, and 33.Results: A total of 392 immunohistochemical slides were analyzed in this study. In the progression from normal epithelium to high-grade dysplasia, we found significant differences in the expression of all biomarkers. A cutoff of 25% or 50% lesional immunopositivity for the 4 MCMs, Ki-67, and p16 resulted in 100% sensitivity and 100% specificity to diagnose high-grade AIN. Sensitivity and specificity of PCNA and p21 for a high-grade AIN diagnosis were lower. HPV-DNA was detectable in 100% of high-grade AIN and 87.5% of low-grade AIN lesions. All MCMs, p16, Ki-67, and PCNA, but not p21 correlated with cumulative lesional high-grade HPV-DNA loads.Limitations: The relatively small number of samples is a limitation, especially for adequate subgroup analyses.Conclusions: MCMs, Ki67, and p16 are reliable immunohistochemical adjuncts for diagnosing high-grade AIN.

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

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.

Incidence of psoriasis in children: A population-based study - Corrected Proof

Megha M. Tollefson, Cynthia S. Crowson, Marian T. McEvoy, Hilal Maradit Kremers — 2009-12-07

Background: Although psoriasis is considered to have a dual peak in age of onset, currently no studies exist regarding the incidence of psoriasis in children.Objective: The objective of this study was to determine the incidence of psoriasis in childhood.Methods: A population-based incidence cohort of patients aged younger than 18 years first given the diagnosis of psoriasis between January 1, 1970, and December 31, 1999, was assembled. The complete medical record of each child was reviewed and psoriasis diagnosis was validated by a confirmatory diagnosis in the medical record by a dermatologist or medical record review by a dermatologist. Age- and sex-specific incidence rates were calculated and were age and sex adjusted to 2000 US white population.Results: The overall age- and sex-adjusted annual incidence of pediatric psoriasis was 40.8 per 100,000 (95% confidence interval: 36.6-45.1). When psoriasis diagnosis was restricted to dermatologist-confirmed subjects in the medical record, the incidence was 33.2 per 100,000 (95% confidence interval: 29.3-37.0). Incidence of psoriasis in children increased significantly over time from 29.6 per 100,000 in 1970 through 1974 to 62.7 per 100,000 in 1995 through 1999 (P < .001). Chronic plaque psoriasis was the most common type (73.7%), and the most commonly involved sites were the extremities (59.9%) and the scalp (46.8%).Limitations: The population studied was a mostly white population in the upper Midwest.Conclusion: The incidence of pediatric psoriasis increases with increasing age. There is no apparent dual peak in incidence. The incidence of pediatric psoriasis increased in recent years in both boys and girls.

Leg ulcer and thigh telangiectasia associated with natural killer cell CD56– large granular lymphocyte leukemia in a patient with pseudo-Felty syndrome - Corrected Proof

2009-12-04

Clonal disorders of large granular lymphocytes (LGL) represent a rare spectrum of biologically distinct lymphoproliferative diseases originating either from mature T cells or natural killer cells. Both subtypes can manifest as indolent or aggressive disorders. We report a 77-year-old woman with rheumatoid arthritis, splenomegaly, and neutropenia who developed a painful leg ulcer refractory to treatment and thigh telangiectatic lesions. Because of the association of rheumatoid arthritis, splenomegaly, and nonspecific neutropenia, the diagnosis of Felty syndrome was initially made. Further investigation allowed the diagnosis of a CD56– natural killer–cell LGL leukemia and documented skin infiltration by natural killer cells. Cutaneous manifestations of LGL leukemia have been rarely reported. This report of pseudo-Felty syndrome with CD56– LGL leukemia, presenting with a leg ulcer and telangiectasia, enhances the role of dermatology in the diagnosis of hematologic neoplasia.

Factors affecting sleep quality in patients with psoriasis - Corrected Proof

Smitha Gowda, Orin M. Goldblum, W. Vaughn McCall, Steven R. Feldman — 2009-11-30

Poor sleep quality adversely affects quality of life in patients with psoriasis. However, the factors impairing sleep in these patients have not been well described. We reviewed the available literature linking sleep quality and psoriasis to elucidate factors that interfere with sleep. Pruritus, depression, pain, and obstructive sleep apnea may be likely sources of sleep impairment in patients with psoriasis. Fatigue resulting from sleep interference may also be implicated in this relationship. Pruritus, depression, and pain interfere with sleep quality by increasing nocturnal awakenings and sleep fragmentation. Obstructive sleep apnea may occur in a greater percentage of patients with psoriasis than control populations. Factors associated with psoriasis appear to have similarities in their cytokine and neuropeptide profiles. Moreover, these variables are complex and interconnected. Further study and awareness of potential factors impacting sleep in patients with psoriasis may provide new avenues for treatment of recalcitrant disease.

Cyclosporine and psoriasis: 2008 National Psoriasis Foundation∗ Consensus Conference - Corrected Proof

David M. Rosmarin, Mark Lebwohl, Boni E. Elewski, Alice B. Gottlieb — 2009-11-25

Background: Cyclosporine is a valuable option for the treatment of psoriasis. This report summarizes studies regarding the use of cyclosporine since the last guidelines were published in 1998.Objective: A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to achieve a consensus on new updated guidelines for the use of cyclosporine in the treatment of psoriasis.Methods: Reports in the literature were reviewed regarding cyclosporine therapy.Limitations: There are few evidence-based studies on the treatment of psoriasis with cyclosporine.Results: A consensus was achieved on the use of cyclosporine in psoriasis including specific recommendations on dosing, monitoring, and use of cyclosporine in special situations. The consensus received approval from members of the National Psoriasis Foundation Medical Board.Conclusions: Cyclosporine is a safe and effective drug for the treatment of psoriasis. It has a particularly useful role in managing psoriatic crises, treating psoriasis unresponsive to other modalities, bridging to other therapies, and treating psoriasis within a rotational scheme of other medications. Appropriate patient selection and monitoring will significantly decrease the risks of side effects.

Erythema multiforme during anti–tumor necrosis factor treatment for plaque psoriasis - Corrected Proof

Jennifer Ahdout, Jennifer C. Haley, Melvin W. Chiu — 2009-11-16

Tumor necrosis factor alpha (TNF-α) inhibitors constitute a class of biologic treatments utilized in the management of psoriasis. We report a case of a patient treated for chronic plaque psoriasis with the anti-TNF-α monoclonal antibody adalimumab, who developed erythema multiforme (EM). The patient had previously developed EM on two occasions while taking the TNF-α inhibitor etanercept. EM has previously been reported in connection with other TNF-α inhibitors, including etanercept and infliximab. To our knowledge, this is the first case reported in the literature documenting EM occurring subsequent to adalimumab treatment for psoriasis. The recurrent development of EM in our patient while being treated with distinct TNF-α inhibitors may suggest that EM is the consequence of a class effect with TNF-α inhibitors.

Efficacy and safety of treatments for childhood psoriasis: A systematic literature review - Corrected Proof

2009-11-09

Background: Evidence-based recommendations for therapeutic decision making in childhood psoriasis are lacking.Objectives: We sought to systematically review all available literature concerning treatment efficacy and safety in childhood psoriasis and to propose a recommendation for topical and systemic treatment of childhood psoriasis.Methods: Databases searched were PubMed, EMBASE, and the Cochrane Controlled Clinical Trial Register. All studies reporting on efficacy and safety of all treatment options in childhood psoriasis were obtained and a level of evidence was determined.Results: Literature search revealed 2649 studies, of which 64 studies met the inclusion criteria. The majority of topical and systemic therapies given in childhood psoriasis are efficacious. Short-term side effects were usually mild; long-term side effects were not described.Limitations: Most conclusions formulated are not based on randomized controlled trials.Conclusions: A rough summary of the proposed algorithm is as follows: first, calcipotriene with/without topical corticosteroids, followed by dithranol. Methotrexate is considered to be the systemic treatment of choice.

Spatiotemporal expression pattern of neuroepithelial stem cell marker nestin suggests a role in dermal homeostasis, neovasculogenesis, and tumor stroma development: A study on embryonic and adult human skin - Corrected Proof

Klaus Sellheyer, Dieter Krahl — 2009-10-28

Background: Whereas keratinocytic bulge stem cells are well characterized, comparably little is known about cutaneous mesenchymal stem cells. The follicular connective tissue sheath is proposed as a niche for dermal stem cells.Objective: Because the neuroepithelial stem cell marker nestin represents a marker for mesenchymal stem cells in various tissues, our aim was to characterize its spatiotemporal expression pattern in the skin with special reference to the follicular mesenchyme.Methods: We studied immunohistochemically nestin expression over the course of human cutaneous embryogenesis, in postnatal skin, in scalp wounds, and in the peritumoral stroma of basal cell carcinomas and compared its expression with that of other known mesenchymal markers.Results: Nestin is expressed throughout the entire early embryonic dermis but confined later during development to the follicular connective tissue sheath, where it can also be found in postnatal human hair follicles. Its expression is up-regulated in scalp wounds and the nestin-positive cells seem to originate from the follicular mesenchyme. Nestin is also expressed in a thin layer of fibroblasts in the immediate vicinity of basal cell carcinomas.Limitations: The examination for nestin expression of scalp wounds is considered preliminary, because we examined scalp wounds representing re-excisions of previously diagnosed neoplasms from which we had no exact time table available as to when the original excision took place.Conclusion: We propose that nestin functions as a stem cell marker of the follicular mesenchyme and has a major regulatory role in dermal homeostasis, cutaneous neovasculogenesis, and tumor stroma development.

Development of Pneumocystis carinii pneumonia in patients with immunobullous and connective tissue disease receiving immunosuppressive medications - Corrected Proof

Jacqueline L. Gerhart, Amer N. Kalaaji — 2009-10-14

Background: Pneumocystis carinii pneumonia (PCP) causes morbidity and mortality in immunocompromised hosts. Data describing use of PCP prophylaxis in immunosuppressed dermatologic patients are lacking.Objective: We sought to describe the frequency of PCP among dermatologic patients receiving immunosuppression for immunobullous disease or connective tissue disease.Methods: We retrospectively reviewed the cases of patients with immunobullous and connective tissue disease at our department of dermatology between 1980 and 2006 who received immunosuppression and had subsequent development of pneumonia. We recorded patient characteristics, use of PCP prophylaxis, whether PCP developed, and if so, their morbidity and mortality.Results: Of 334 patients identified, 7 (2.1%) were given the diagnosis of PCP during immunosuppressive treatment. Of these 7 patients, 3 (43%) died within 1 month of diagnosis, and none received PCP prophylaxis.Limitations: Retrospective study design and limited patient group are limitations.Conclusions: PCP prophylaxis may improve outcomes for some patients with immunobullous or connective tissue disease receiving immunosuppressive therapy.

Amelanotic lentigo maligna: A report of three cases and review of the literature - Corrected Proof

Farah Rukhsana Abdulla, Mary Jo Kerns, Diya F. Mutasim — 2009-09-22

Background: Amelanotic lentigo maligna is not clinically suspected and is often mistaken for a basal cell carcinoma, squamous cell carcinoma, or dermatitis.Objective: Our objective was to review previously reported cases of amelanotic lentigo maligna and compare them with our 3 cases.Methods: The clinical presentation and histologic findings of 3 new cases are described and compared with those in the literature.Results: The index of suspicion for amelanotic lentigo maligna is extremely low. No reported cases have been diagnosed clinically. None of our 3 cases was suspected.Limitations: Only three cases were reviewed.Conclusion: A high degree of clinical and histologic suspicion is required to make the diagnosis of this clinically nondescript neoplasm.

An outbreak of Mycobacterium chelonae infections in tattoos - Corrected Proof

2009-09-07

Nontuberculous mycobacteria infections may occur after cutaneous procedures. Review of the medical records of patients who developed a rash within a tattoo revealed 6 patients with skin infections caused by Mycobacterium chelonae after receiving tattoos by one artist at a single tattoo establishment. The interval between tattoo placement and the skin findings was 1 to 2 weeks. All patients received alternate diagnoses before mycobacterial infection was identified. Skin findings included pink, red, or purple papules; papules with scale; pustules; granulomatous papules; and lichenoid papules and plaques. Histopathologic examination revealed granuloma, lymphohistiocytic infiltrate, or mixed inflammation; acid-fast bacilli stains produced negative results. Diagnosis was made by culture in 3 patients, histopathology in two patients, and clinical/epidemiologic association in one patient. The M chelonae isolates were clarithromycin susceptible, and the infections responded to macrolide antibiotics. Physicians should consider mycobacterial infections in patients with skin findings within a new tattoo.

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

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. (J Am Acad Dermatol doi:10.1016/j.jaad.2009.05.048.)

Treatment of acne conglobata with modern external beam radiation - Corrected Proof

Joseph N. Myers, Ashley R. Mason, Lori K. Gillespie, Kimberly S. Salkey — 2009-08-10

Like other diseases of the follicular occlusion tetrad, acne conglobata can be difficult to treat. We describe the successful use of modern external beam radiation for acne conglobata in the case of a 53-year-old man with long-standing and disfiguring acne conglobata and hidradenitis suppurativa. For patients with severe acne conglobata resistant to more accepted therapies, modern external beam radiation may be a viable alternative on the therapeutic ladder.