JAMA Dermatology Current Issue

“Granulomatosis With Polyangiitis (Wegener's)” for “Wegener Granulomatosis” Dermatology Journals Should Also Adopt the Alternative Name Granulomatosis With Polyangiitis (Wegener's)

Bachmeyer C, Halioua B. — Wed, 01 May 2013 00:00:00 GMT

Recently, Galve et al reported a quiz case describing a patient with grouped papules and vesicles indicating “Wegener granulomatosis.” This is the opportunity to comment on the name given to this disease. Indeed, we have no doubt that ethical considerations should be introduced into medical nomenclature and nosology, particularly for eponyms—a name given to a disease or condition, semiological signs, or anatomical area based on the name of a person to honor his or her finding.

Medicamina Faciei Femineae : Roman Skin Care

Ali FR, Fox J, Finlayson AT. — Wed, 01 May 2013 00:00:00 GMT

A Female Pioneer—Doubly Recognized

Burgdorf WC, Hoenig LJ. — Wed, 01 May 2013 00:00:00 GMT

Eponyms abound in dermatology, giving recognition to those who have advanced the specialty. Behind eponyms, there are often tales about physicians, patients, and the times in which they lived.

A Maroon Plaque in an Infant

Wang C, Ma L, Savory S, et al. — Wed, 01 May 2013 00:00:00 GMT

Large congenital masses appropriately raise clinical concern, especially when they do not present with the classic appearance, thus requiring consideration of broad differential diagnostic categories prior to conclusive diagnosis. We discuss analysis and treatment of a vascular lesion most closely resembling a fibrous hamartoma of infancy (FHI).

A Palpable Erythematous Cord Over the Trunk in a Patient With Systemic Lupus Erythematosus—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

A Palpable Erythematous Cord Over the Trunk in a Patient With Systemic Lupus Erythematosus—Quiz Case

Wong HK, Kaffenberger BH, Zirwas M. — Wed, 01 May 2013 00:00:00 GMT

A Rapidly Enlarging Nodule on the Dorsal Aspect of the Nose—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

A Rapidly Enlarging Nodule on the Dorsal Aspect of the Nose—Quiz Case

Chapman I, Litzner B, Jacobe H. — Wed, 01 May 2013 00:00:00 GMT

About This Journal

Wed, 01 May 2013 00:00:00 GMT

Association of Androgenetic Alopecia With Mortality From Diabetes Mellitus and Heart Disease Androgenetic Alopecia and Mortality

Su L, Chen L, Lin S, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Identifying predictors of mortality from diabetes mellitus (DM) and heart disease can help shape treatment strategies. Presence of androgenetic alopecia (AGA) might be such a predictor.

Objective

To determine whether the presence of AGA is associated with an elevated rate of mortality from DM and heart disease in both sexes after adjustment for potential confounders.

Design

A population-based prospective cohort study.

Setting

Community-based integrated screening in Taiwan.

Participants

A total of 7252 subjects aged 30 to 95 years participated in the baseline AGA survey using the Norwood and Ludwig classifications between April and June 2005. Baseline information on metabolic syndrome (MetS) and other possible risk factors was also collected. We then followed this cohort over time to ascertain death and cause of death until December 2010.

Interventions or Exposures

Application of Norwood and Ludwig ALA classifications to study population.

Main Outcomes and Measures

Deaths from DM and heart disease.

Results

Among the 7126 subjects (2429 men and 4697 women) who provided complete data, there were 70 deaths from DM and heart disease during the 57-month follow-up period. Subjects with moderate to severe AGA vs normal or mild AGA had a significantly higher risk of mortality from DM (adjusted hazard ratio [HR], 2.97; 95% CI, 1.26-7.01) (P = .01) and heart disease (adjusted HR, 2.28; 95% CI, 1.00-5.23) (P = .05) after adjusting for age, family history of DM or heart disease, and MetS.

Conclusions and Relevance

AGA is an independent predictor of mortality from DM and heart disease in both sexes. This finding may have significant implications for the identification of risk factors for DM and heart disease in patients with moderate or severe AGA, regardless of whether MetS is present.

Dasatinib-Induced Leukotrichia in a Patient With Chronic Myelogenous Leukemia

Samimi S, Chu E, Seykora J, et al. — Wed, 01 May 2013 00:00:00 GMT

Dasatinib, a thiazole carboxamide derivative, is a second-generation tyrosine kinase inhibitor (TKI), similar in structure to imatinib, that is used for the treatment of chronic myelogenous leukemia (CML). We report a case of extensive dasatinib-induced leukotrichia in a patient with refractory CML.

Diffuse Umbilicated Vesicles in a Critically Ill Child

Chang L, Cassarino D, Sosa V. — Wed, 01 May 2013 00:00:00 GMT

Methicillin-resistant Staphylococcus aureus (MRSA) septicemia can produce disseminated skin lesions, but a vesicular eruption is not a well-recognized presentation of this infection.

Effect of Store and Forward Teledermatology on Quality of Life A Randomized Controlled Trial Store and Forward Teledermatology

Whited JD, Warshaw EM, Edison KE, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Although research on quality of life and dermatologic conditions is well represented in the literature, information on teledermatology's effect on quality of life is virtually absent.

Objective

To determine the effect of store and forward teledermatology on quality of life.

Design

Two-site, parallel-group, superiority randomized controlled trial.

Setting

Dermatology clinics and affiliated sites of primary care at 2 US Department of Veterans Affairs medical facilities.

Participants

Patients being referred to a dermatology clinic were randomly assigned, stratified by site, to teledermatology or the conventional consultation process. Among the 392 patients who met the inclusion criteria and were randomized, 326 completed the allocated intervention and were included in the analysis.

Interventions

Store and forward teledermatology (digital images and a standardized history) or conventional text-based consultation processes were used to manage the dermatology consultations. Patients were followed up for 9 months.

Main Outcome Measures

The primary end point was change in Skindex-16 scores, a skin-specific quality-of-life instrument, between baseline and 9 months. A secondary end point was change in Skindex-16 scores between baseline and 3 months.

Results

Patients in both randomization groups demonstrated a clinically significant improvement in Skindex-16 scores between baseline and 9 months with no significant difference by randomization group (P = .66, composite score). No significant difference in Skindex-16 scores by randomization group between baseline and 3 months was found (P = .39, composite score).

Conclusions

Compared with the conventional consultation process, store and forward teledermatology did not result in a statistically significant difference in skin-related quality of life at 3 or 9 months after referral.

Trial Registration

clinicaltrials.gov Identifier: NCT00488293

Eruptive Melanocytic Nevi in a Patient Undergoing Treatment With Sunitinib

Jiménez-Gallo D, Albarrán-Planelles C, Linares-Barrios M, et al. — Wed, 01 May 2013 00:00:00 GMT

The onset of eruptive melanocytic nevi (EMN) is an uncommon phenomenon characterized by sudden onset of multiple melanocytic nevi (MN). This phenomenon has been linked primarily to bullous diseases or conditions of immunosuppression. A newly described cause of EMN is the multikinase inhibitor sorafenib and its relationship to inhibition of the BRAF^V600E mutation (Table).

Facial Stigmata and Their Powerful Effects in Literature and Life

Thorne A. — Wed, 01 May 2013 00:00:00 GMT

Factors Predictive of Recurrence and Death From Cutaneous Squamous Cell Carcinoma A 10-Year, Single-Institution Cohort Study Recurrence and Death From CSCC

Schmults CD, Karia PS, Carter JB, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Although most cases of cutaneous squamous cell carcinoma (CSCC) are easily cured with surgery or ablation, a subset of these tumors recur, metastasize, and cause death. We conducted the largest study of CSCC outcomes since 1968.

Objective

To identify risk factors independently associated with poor outcomes in primary CSCC.

Design

A 10-year retrospective cohort study.

Setting

An academic hospital in Boston.

Participants

Nine hundred eighty-five patients with 1832 tumors.

Main Outcomes and Measures

Subhazard ratios for local recurrence, nodal metastasis, disease-specific death, and all-cause death adjusted for presence of known prognostic risk factors.

Results

The median follow-up was 50 (range, 2-142) months. Local recurrence occurred in 45 patients (4.6%) during the study period; 36 (3.7%) developed nodal metastases; and 21 (2.1%) died of CSCC. In multivariate competing risk analyses, independent predictors for nodal metastasis and disease-specific death were a tumor diameter of at least 2 cm (subhazard ratios, 7.0 [95% CI, 2.2-21.6] and 15.9 [4.8-52.3], respectively), poor differentiation (6.1 [2.5-14.9] and 6.7 [2.7-16.5], respectively), invasion beyond fat (9.3 [2.8-31.1] and 13.0 [4.3-40.0], respectively), and ear or temple location (3.8 [1.1-13.4] and 5.9 [1.3-26.7], respectively). Perineural invasion was also associated with disease-specific death (subhazard ratio, 3.6 [95% CI, 1.1-12.0]), as was anogenital location, but few cases were anogenital. Overall death was associated with poor differentiation (subhazard ratio, 1.3 [95% CI, 1.1-1.6]) and invasion beyond fat (1.7 [1.1-2.8]).

Conclusions and Relevance

Cutaneous squamous cell carcinoma carries a low but significant risk of metastasis and death. In this study, patients with CSCC had a 3.7% risk of metastasis and 2.1% risk of disease-specific death. Tumor diameter of at least 2 cm, invasion beyond fat, poor differentiation, perineural invasion, and ear, temple, or anogenital location were risk factors associated with poor outcomes. Accurate risk estimation of outcomes from population-based data and clinical trials proving the utility of disease-staging modalities and adjuvant therapy is needed.

Flexural Agminated Eruptive Nevi in Langerhans Cell Histiocytosis

Surinach C, Bahadoran P, Vabres P, et al. — Wed, 01 May 2013 00:00:00 GMT

Langerhans cell histiocytosis (LCH) is a multisystemic disease of childhood characterized by abnormal clonal proliferation of Langerhans cells, with skin lesions often involving flexural areas. We report 2 cases of eruptive nevi seen in skin folds of children with LCH.

Foreign-Body Reaction to Wound Seal

Lester LJ, Joseph AK. — Wed, 01 May 2013 00:00:00 GMT

Wound Seal (Biolife LLC) is a product composed of a hydrophilic polymer and potassium iron oxyacid salt that aids in hemostasis in wounds that are left to heal by secondary intention. We report a foreign-body reaction that results in the dermis following its use.

Harnessing Hedgehog for the Treatment of Basal Cell Carcinoma Hedgehog for Treatment of Basal Cell Carcinoma

Harms KL, Dlugosz AA. — Wed, 01 May 2013 00:00:00 GMT

Vismodegib, a first-in-class small-molecule hedgehog pathway inhibitor, was approved by the Food and Drug Administration in January 2012 for the treatment of metastatic and locally advanced basal cell carcinoma (BCC). The commentary by Wysong et al in this issue of JAMA Dermatology highlights the poor response of metastatic BCC to conventional forms of therapy, making hedgehog pathway antagonists an important addition to the therapeutic armamentarium for this rare but deadly type of BCC.

Hereditary Benign Telangiectasia: Punctate Telangiectasia Surrounded by Anemic Halo

Arévalo N, Martínez del Sel J, Donatti L, et al. — Wed, 01 May 2013 00:00:00 GMT

Hereditary benign telangiectasia (HBT) is a primary telangiectatic disorder, characterized by the presence of telangiectasias with different morphological features (lineal, punctiform, arborescent, reticulated, or in plaques) on the face, neck, upper trunk, and extremities. The mucosae are not affected, and there is no systemic involvement. Because it is an autosomal dominant disorder, lesions are usually present in several members of a single family.

Immediate Successful Treatment of Argyria With a Single Pass of Multiple Q-Switched Laser Wavelengths

Gottesman SP, Goldberg GN. — Wed, 01 May 2013 00:00:00 GMT

Argyria is a mucocutaneous discoloration caused by exposure to airborne silver particles or long-term ingestion of ionized silver solutions. It is intriguing in the sense that it creates a profound skin color change. It is known that ionized or colloidal silver particles have the highest affinity for dermal elastic fibers and eccrine glands. Once the colloidal silver particles deposit around eccrine glands, they are indeed colorless. It is in the dermal matrix where the silver particles combine with elemental sulfur to form black silver sulfide particles facilitated via a UV-induced reduction reaction.

In This Issue of JAMA Dermatology

Wed, 01 May 2013 00:00:00 GMT

Inconsistency in Clinical Measurements Can Be Improved Through Training Comment on “Standardizing Training for Psoriasis Measures” Inconsistency Improved Through Training

Swerlick RA. — Wed, 01 May 2013 00:00:00 GMT

Neutrophilic Dermatosis After Azathioprine Exposure Neutrophilic Dermatosis and Azathioprine Exposure

Cyrus N, Stavert R, Mason AR, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Azathioprine hypersensitivity syndrome can present clinically and histopathologically like Sweet syndrome. Shared clinical features include fever, constitutional symptoms, prompt response to systemic corticosteroid therapy, neutrophilia, and abrupt onset of erythematous cutaneous lesions. Histologically, both azathioprine hypersensitivity syndrome and Sweet syndrome are rich in neutrophils.

Observations

An 81-year-old woman with Crohn disease presented with fever and an acute eruption of plaques on her extremities within 2 weeks of starting treatment with azathioprine. Laboratory evaluation was notable for leukocytosis and neutrophilia. Skin biopsy of an erythematous plaque on the thigh demonstrated a suppurative folliculitis. Azathioprine treatment was discontinued resulting in resolution of the clinical lesions within 5 days. Our case was compared with 18 cases with similar clinical features.

Conclusions and Relevance

We report a case of azathioprine hypersensitivity syndrome and review the literature on azathioprine-induced eruptions with features of Sweet syndrome. Our patient's distribution of lesions on the extremities and the finding of suppurative folliculitis on histopathology were not classical for Sweet syndrome. Azathioprine hypersensitivity syndrome seems to be a neutrophil-driven dermatosis; therefore, many overlapping features with Sweet syndrome are not surprising. Due to the potential for anaphylaxis with azathioprine rechallenge, a better term for a Sweetlike presentation in the setting of azathioprine administration is azathioprine hypersensitivity syndrome.

Nonmelanoma Skin Cancer in Organ Transplant Recipients: Increase Without Delay After Transplant and Subsequent Acceleration

Muehleisen B, Pazhenkottil A, French LE, et al. — Wed, 01 May 2013 00:00:00 GMT

Organ transplant recipients (OTRs) have a 60- to 250-fold increased risk for cutaneous squamous cell carcinoma (SCC) and a 10-fold increased risk for basal cell carcinoma (BCC). It is still unclear, however, how fast after transplant these tumors arise. To develop risk-adjusted clinical follow-up in OTRs, we investigated the incidence of first and subsequent nonmelanoma skin cancers (NMSCs) in OTRs.

On the Comparison of Diagnosis and Management of Melanoma Between Dermatologists and MelaFind

Cukras AR. — Wed, 01 May 2013 00:00:00 GMT

In a recent issue of JAMA Dermatology, Wells et al compare the recommendations of the MelaFind device (Mela Sciences Inc) with those of 39 dermatologists who did not use MelaFind for sensitivity and specificity of melanoma diagnosis. The specificity of the device was so low that I find the conclusions of the authors that it is a useful and “very sensitive tool to guide dermatologists”^(p1084) not supported by their data. The authors report that on a test set of 47 lesions, MelaFind recommended biopsy in 44 lesions and no biopsy in 3. Of the 3 nonbiopsy lesions, 1 was melanoma.

Perspectives on Acne: What Twitter Can Teach Health Care Providers

Shive M, Bhatt M, Cantino A, et al. — Wed, 01 May 2013 00:00:00 GMT

Acne is one of the most common skin diseases, with an estimated prevalence of 50 million people in the United States alone, and has a significant impact on quality of life. The high prevalence and seriousness of acne makes crafting innovative avenues for patient education about this disease very important. Twitter has become a popular social networking phenomenon with a user base of over 140 million active users and 340 million tweets per day. Its popularity makes it a potentially powerful source of information and route of communication for acne, especially since the Internet can be an adolescent's primary sources of health information.

President Kennedy's White House Tan

Hoenig LJ, Burgdorf WC. — Wed, 01 May 2013 00:00:00 GMT

This year marks the 50th anniversary of the Kennedy assassination. Many of us will never forget that Friday, November 22, 1963, when we heard the tragic news that President John F. Kennedy (1917-1963) had been shot in Dallas, Texas.

Prevalence and Clinical Significance of Anti–Laminin 332 Autoantibodies Detected by a Novel Enzyme-Linked Immunosorbent Assay in Mucous Membrane Pemphigoid Anti–Laminin 332 Autoantibodies Detected by ELISA

Bernard P, Antonicelli F, Bedane C, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

A rare variant of mucous membrane pemphigoid (MMP) is characterized by circulating anti–laminin 332 (Lam332) autoantibodies and seems to be associated with concurrent malignant neoplasms.

Objective

To determine the prevalence and clinical significance of anti-Lam332 autoantibody detection from a large series of patients with MMP.

Design

Multicenter retrospective study.

Setting

Four French national centers for autoimmune bullous diseases.

Participants

One hundred fifty-four patients with MMP and 89 individuals serving as controls were included.

Interventions

Serum samples were analyzed by a new Lam332 enzyme-linked immunosorbent assay (ELISA); clinical and immunopathologic data were obtained from the patients' medical records.

Main Outcome Measures

The Lam332 ELISA scores were evaluated with respect to clinical characteristics, standard and salt-split indirect immunofluorescence, and bullous pemphigoid (BP) 230 and BP180-NC16A ELISAs.

Results

The Lam332 ELISA score was positive (≥9 U/mL) in 20.1% of serum samples from patients with MMP, 1 of 50 patients with bullous pemphigoid (BP), none of 7 with pemphigus, and 3 of 32 other controls. No relationship was evidenced between a positive ELISA Lam332 score and age; sex ratio; oral, ocular, genital, skin, or esophageal/laryngeal involvement; internal malignant neoplasm; or BP180 ELISA score. Salt-split skin indirect immunofluorescence and ELISA BP230 results were more frequently positive when Lam332 ELISA results were positive (P = .04 and .02, respectively). Patients with a positive Lam332 ELISA score frequently had more severe MMP (67.8% vs 47.2%; P = .04).

Conclusions and Relevance

Results of this novel ELISA showed that serum anti-Lam332 autoantibodies are detected in 20.1% of patients with MMP. Anti-Lam332 autoantibodies are mainly detected in patients with severe MMP but not preferentially in those with a malignant neoplasm. The association between anti-Lam332 and anti-BP230 autoantibodies might arise from an epitope-spreading phenomenon.

Prevalence of Pilomatricoma in Turner Syndrome Findings From a Multicenter Study Prevalence of Pilomatricoma in Turner Syndrome

Handler MZ, Derrick KM, Lutz RE, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

The absence of data on the prevalence of pilomatricoma among patients with Turner syndrome served as the catalyst for this multicenter investigation.

Objectives

To ascertain the prevalence of pilomatricoma among patients with Turner syndrome and to determine any association between the development of pilomatricomas and the use of exogenous hormones in patients with Turner syndrome.

Design

A retrospective medical record review from January 1, 2000, through January 1, 2010, was performed of all patients with Turner syndrome. Data on pilomatricomas and the use of hormone therapy were collected.

Setting

University of California–Davis Medical Center, University of Nebraska Medical Center, and The University of North Carolina at Chapel Hill.

Participants

Patients with a diagnosis of Turner syndrome.

Main Outcome Measures

Prevalence of concomitant pilomatricoma and diagnosis of Turner syndrome. Secondary outcome measures included the use of the exogenous hormones estrogen or recombinant human growth hormone (rhGH).

Results

In total, 311 patients with Turner syndrome were identified from these 3 institutions. Among them, 8 patients (2.6%) were diagnosed as having pilomatricomas. Before the development of pilomatricomas, 5 patients had been treated with rhGH but not estrogen, 1 patient had received estrogen but not rhGH, and 2 patients did not receive either therapy.

Conclusions and Relevance

Although the prevalence of pilomatricoma among the general population is unknown, this study demonstrates a high prevalence (2.6%) of pilomatricomas among patients with Turner syndrome. No apparent relationship was noted among our patients or in the literature between the use of rhGH and the development of pilomatricomas.

Pruritus Ani, Recurring After Plastic Operation for Its Cure.

Wed, 01 May 2013 00:00:00 GMT

THE JOURNAL OF CUTANEOUS DISEASESVOL. XXXIMAY, 1913NO. 5

Pseudoepitheliomatous Hyperplasia: An Unusual Tattoo Reaction

Breza TS, O’Brien AK, Glavin FL. — Wed, 01 May 2013 00:00:00 GMT

Pseudoepitheliomatous hyperplasia (PEH) is a rare tattoo reaction often arising within areas of red or purple ink. The diagnosis and treatment can be challenging. We report herein the first case to our knowledge of PEH tattoo reaction treated with carbon dioxide laser.

Reliability and Convergent Validity of the Cutaneous Sarcoidosis Activity and Morphology Instrument for Assessing Cutaneous Sarcoidosis Assessment of Cutaneous Sarcoidosis

Rosenbach M, Yeung H, Chu EY, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

A validated scoring system is essential to assess the effect of therapeutic interventions on a disease. The instrument introduced here captures sarcoidosis disease activity in a reliable, reproducible manner, which will help standardize clinical trial outcomes and allow comparative efficacy studies in the future and may help lead to more robust data regarding the effect of different treatments on cutaneous sarcoidosis.

Objective

To assess the reliability and convergent validity of the Cutaneous Sarcoidosis Activity and Morphology Instrument (CSAMI) and Sarcoidosis Activity and Severity Index (SASI) for evaluating cutaneous sarcoidosis outcomes.

Design and Setting

Cross-sectional study evaluating cutaneous sarcoidosis disease severity using CSAMI, SASI, and Physician's Global Assessment (PGA) as reference in the dedicated cutaneous sarcoidosis clinic of a teaching hospital.

Participants

Eight dermatologists evaluating cutaneous sarcoidosis in 11 patients.

Intervention

Evaluation using the study instruments.

Main Outcomes and Measures

Primary outcomes included interrater and intrarater reliability and convergent validity; secondary outcomes, correlation with quality-of-life measures and time required for completion.

Results

All instruments demonstrated good to excellent intrarater reliability. Interrater reliability was excellent for CSAMI Activity scores (intraclass correlation coefficient, 0.82 [95% CI, 0.66-0.94]) and fair to poor for CSAMI Damage scores (0.42 [0.21-0.72]), modified Facial SASI (0.40 [0.17-0.72]), and PGA scores (0.40 [0.18-0.70]). CSAMI Activity and Damage scores and modified Facial SASI all demonstrated convergent validity with statistically significant correlations with PGA scores. Trends for correlations were seen between CSAMI scores and specific Skindex-29 quality-of-life domains. Although CSAMI required longer time to complete than SASI, both were scored within adequate time for use in clinical trials.

Conclusions and Relevance

CSAMI appears to be a reliable and valid outcome instrument to measure cutaneous sarcoidosis and may capture a wide range of body surface and cutaneous morphologic types. This instrument can be adopted into clinical practice and clinical trials to allow physicians to assess the intensity of their patients' cutaneous sarcoidosis disease activity. Widespread use of one metric for disease severity assessment can help standardize the evaluation of the effect of various treatments on the disease. Future research is necessary to demonstrate its sensitivity to change and to confirm its correlation with quality-of-life measures.

Rerecurrence 5 Years After Treatment of Recurrent Cutaneous Basal Cell and Squamous Cell Carcinoma

Hamilton JR, Parvataneni R, Stuart SE, et al. — Wed, 01 May 2013 00:00:00 GMT

Cutaneous basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) that have recurred after previous treatment are considered more difficult to cure compared with primary tumors, with overall 5-year re-recurrence rates reported as high as 15.4% for BCC and 5.9% for SCC. Few outcomes data exist from prospective studies, but a randomized controlled study in Europe of facial BCCs found that 5-year recurrence rates after excision or Mohs surgery for 397 primary tumors varied from 2.5% to 4.1%, compared with 2.4% to 12.1% for 202 recurrent tumors. The generalizability of these results to the United States, to other BCCs and SCCs, and after treatments delivered in the community is not clear. We sought to determine the 5-year recurrence rate after treatment of a consecutive cohort of BCCs and SCCs already recurrent at presentation.

Resistance of Acellular Dermal Matrix Materials to Microbial Penetration Acellular Dermal Matrix Materials

Fahrenbach EN, Qi C, Ibrahim O, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Acellular dermal matrices have many current and potential applications, but their long-term safety has not been extensively studied. In particular, limited information exists regarding such materials' resistance to infection.

Objective

To assess the resistance to microbial penetration of common acellular dermal matrix materials used in reconstruction after skin cancer excision, treatment of chronic ulcers and burns, breast reconstruction, hernia repairs, and other applications.

Design

Comparative in vitro study of 4 commercially available dermal substitutes for their ability to act as barriers to penetration by common skin pathogens.

Setting

University-based dermatology and plastic surgery departments and a hospital microbiology laboratory.

Materials

Four commercially available dermal substitutes, including AlloDerm (LifeCell), FlexHD (Musculoskeletal Transplant Foundation), Strattice (LifeCell), and NeoForm (Mentor Corporation).

Intervention

We tested the 4 dermal matrix materials with the following 4 organisms commonly implicated in wound infections: Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pyogenes, and Candida albicans. Each material was inoculated with the same concentration of each pathogen.

Main Outcome Measure

The number of bacterial colonies grown on blood agar plates.

Results

AlloDerm and rehydrated FlexHD were found to be the best barriers to penetration by P aeruginosa. AlloDerm, FlexHD, and Strattice also prevented penetration by S aureus and S pyogenes; NeoForm was less effective in withstanding these organisms. The results of this study were inconclusive with regard to C albicans penetration.

Conclusions and Relevance

Three of the 4 commonly used acellular dermal matrix materials are resistant to in vitro penetration by S aureus and S pyogenes and partially resistant to P aeruginosa. Resistance to fungal pathogens is uncertain. Antimicrobial differences across matrix materials may influence their selection for particular uses, such as treatment of refractory leg ulcers or reconstruction after skin cancer excision.

Saliva Polymerase Chain Reaction Assay for Detection and Follow-up of Herpesvirus Reactivation in Patients With Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) HHV Reactivation in Systemic Drug Reactions

Descamps V, Avenel-Audran M, Valeyrie-Allanore L, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Reactivations of human herpesviruses (HHVs) contribute to the development of drug reaction with eosinophilia and systemic symptoms (DRESS). Diagnosis of HHV reactivation is conventionally based on quantitative real-time polymerase chain reaction (PCR) analysis of blood samples, but these viruses are present in the oropharynx and are shed in saliva.

Objective

To evaluate the use of a saliva PCR assay for demonstrating HHV shedding in patients with DRESS.

Design

Shedding of HHV in saliva was prospectively studied in patients with DRESS. Reactivations of HHV, including HHV-6, HHV-7, cytomegalovirus (CMV), and Epstein-Barr virus (EBV), were studied by performing quantitative real-time PCR analysis of blood samples obtained at admission) and serial samples of saliva obtained within the first 2 weeks of DRESS; saliva samples from controls were compared.

Participants

The study included 5 patients who met definite criteria for DRESS and 15 controls (5 immunosuppressed patients and 10 healthy adults).

Main Outcome Measures

DNA viral loads of HHV, including HHV-6, HHV-7, CMV, and EBV as measured with real-time PCR in blood and saliva samples from patients with DRESS and saliva samples from immunosuppressed and healthy controls.

Results

The PCR assay demonstrated shedding of HHV-7, EBV, HHV-6, and CMV, listed by order of magnitude. The DNA viral loads in blood and saliva samples, also measured with real-time PCR, were found to be close. In 1 patient, reactivations in saliva preceded clinical manifestations of CMV disease. Significant production of HHV-7 and EBV was demonstrated in saliva samples from the controls, but neither HHV-6 nor CMV were detected.

Conclusions and Relevance

The saliva PCR assay is a useful tool for demonstration and follow-up of HHV reactivation. The interpretation of HHV viral loads in saliva differs according to HHV type.

Solitary Cerebriform Nodule—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Solitary Cerebriform Nodule—Quiz Case

Marchetti M, Russell M. — Wed, 01 May 2013 00:00:00 GMT

Solitary, Enlarging Painful Violaceous Tumor on the Cheek of a 10-Year-Old—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Solitary, Enlarging Painful Violaceous Tumor on the Cheek of a 10-Year-Old—Quiz Case

Little AJ, Martinez-Diaz GJ, Gehris RP. — Wed, 01 May 2013 00:00:00 GMT

Standardizing Training for Psoriasis Measures Effectiveness of an Online Training Video on Psoriasis Area and Severity Index Assessment by Physician and Patient Raters Standardizing Training for Psoriasis Measures

Armstrong AW, Parsi K, Schupp CW, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Because the Psoriasis Area and Severity Index (PASI) is the most commonly used and validated disease severity measure for clinical trials, it is imperative to standardize training to ensure reliability in PASI scoring for accurate assessment of disease severity.

Objective

To evaluate whether an online PASI training video improves scoring accuracy among patients with psoriasis and physicians on first exposure to PASI.

Design

This equivalency study compared PASI assessment performed by patients and PASI-naive physicians with that of PASI-experienced physicians at baseline and after standardized video training. The study was conducted from March 15, 2011, to September 1, 2011.

Setting

Outpatient psoriasis clinic at University of California, Davis.

Participants

Forty-two psoriasis patients and 14 PASI-naive physicians participated in the study. The scores from 12 dermatologists experienced in PASI evaluation were used as the criterion standard against which other scores were compared.

Main Outcome Measures

Aggregate and component PASI scores from image sets corresponding to mild, moderate, and severe psoriasis.

Results

After viewing the training video, PASI-naive physicians produced equivalent scores for all components of PASI; patients provided equivalent scores for most PASI components, with the exception of area scores for moderate-to-severe psoriasis images. After the online video training, the PASI-naive physicians and patients exhibited improved accuracy in assigning total PASI scores for mild (Mean_{experienced physician} − Mean_{PASI-naive physician}: 1.2; Mean_{experienced physician} − Mean_patient: −2.1), moderate (Mean_{experienced physician} − Mean_{PASI-naive physician}:0; Mean_{experienced physician} − Mean_patient: −5.7), and severe (Mean_{experienced physician} − Mean_{PASI-naive physician}: −5.1; Mean_{experienced physician} − Mean_patient: −10.4) psoriasis, respectively.

Conclusions and Relevance

Use of an online PASI training video represents an effective tool in improving accuracy in PASI scoring by both health care professionals and patients. The video-based online platform for disseminating standardized training on the use of validated instruments in dermatology represents a novel form of standardized education.

Successful Treatment With Vemurafenib in BRAF V600K–Positive Cerebral Melanoma Metastasis

Forschner A, Niessner H, Bauer J, et al. — Wed, 01 May 2013 00:00:00 GMT

More than 90% of the BRAF mutations in melanoma are identified at codon 600, and about 80% of these are BRAF V600E mutations. The second most common mutation is the BRAF V600K mutation, representing 14% to 28% of BRAF mutations in melanoma. Vemurafenib treatment for metastatic melanoma has been extensively studied in patients harboring the BRAF V600E mutation. There are rare data concerning the BRAF V600K mutation.

Surgical Excision After Neoadjuvant Therapy With Vismodegib for a Locally Advanced Basal Cell Carcinoma and Resistant Basal Carcinomas in Gorlin Syndrome

Chang AS, Atwood SX, Tartar DM, et al. — Wed, 01 May 2013 00:00:00 GMT

Vismodegib is useful to treat locally advanced or metastatic basal cell carcinomas (BCCs), but to our knowledge, its use as a neoadjuvant to shrink BCCs before surgery has not been reported. This case illustrates the role of vismodegib as a neoadjuvant agent. In addition, this case highlights the fact that a patient with Gorlin syndrome can develop resistant BCCs while taking vismodegib, a phenomenon not widely recognized although recently reported.

The American Suntanning Association A “Science-First Organization” With a Biased Scientific Agenda The American Suntanning Association

Stapleton JL, Coups EJ, Hillhouse J. — Wed, 01 May 2013 00:00:00 GMT

UV indoor tanning (IT) is a $5 billion-a-year industry in the United States and remains popular despite a growing scientific literature that demonstrates a link between IT and melanoma. The body of evidence linking melanoma to IT has prompted numerous national and international organizations to advocate the avoidance of IT. This list includes the American Medical Association, the American Academy of Dermatology, the US Department of Health and Human Services, and the World Health Organization, among others. In addition, an increasing number of US states have passed or introduced legislation designed to restrict access to IT among minors. The IT industry has invested heavily in lobbying efforts to prevent such legislation. The Indoor Tanning Association (ITA) represents the interest of IT manufacturers, suppliers, and salon owners and has seemingly had success at counteracting some legislative efforts (including recent failed efforts to ban access to IT among minors in New Jersey).

The Use of Aprepitant in Brachioradial Pruritus

Ally MS, Gamba CS, Peng DH, et al. — Wed, 01 May 2013 00:00:00 GMT

Brachioradial pruritus (BRP) is characterized by intractable itching localized to the dorsolateral aspects of the arms. Aprepitant (Emend; Merck & Co Inc), approved in 2003 for chemotherapy-induced nausea and vomiting, has been used successfully to treat patients with chronic pruritus, but to our knowledge, its use in BRP has not yet been reported.

Tick Removal With Liquid Nitrogen

Pavlovic M, Alakeel A, Frances C. — Wed, 01 May 2013 00:00:00 GMT

Lyme disease is a tick-borne zoonosis caused by Borrelia burgdorferi. A causative organism is transmitted via tick bite, Ixodes ricinus in Europe and neighboring parts of North Africa, and Ixodes scapularis and Ixodes pacificus on the west coast of North America. Erythema chronicum migrans is the first, the most common, and the most specific clinical manifestation and a defining criterion for Lyme disease.

Top-Accessed Article: Text-Message Reminders to Improve Sunscreen Use

Eide MJ. — Wed, 01 May 2013 00:00:00 GMT

Armstrong AW, Watson AJ, Makredes M, Frangos JE, Kimball AB, Kvedar JC. Text-message reminders to improve sunscreen use: a randomized, controlled trial using electronic monitoring. Arch Dermatol. 2009;145(11):1230-1236.

Topical Tazarotene for the Treatment of Ectropion in Ichthyosis Topical Tazarotene for Ectropion in Ichthyosis

Craiglow BG, Choate KA, Milstone LM. — Wed, 01 May 2013 00:00:00 GMT

Importance

Ectropion is a complication of certain subtypes of ichthyosis and is often associated with substantial medical and cosmetic consequences. At present there is no standard of care for the treatment of ectropion in this population. Retinoids cause dyshesion and thinning of stratum corneum, thereby reducing hyperkeratosis that likely underlies ectropion in patients with ichthyosis. As such, retinoids provide a potential effective treatment for ectropion in this group of patients.

Observation

We describe a patient with recessive ichthyosis for whom daily application of topical tazarotene produced rapid and persistent improvement of bilateral lower eyelid ectropion without adverse effects.

Conclusions and Relevance

Additional studies will be necessary to more fully and systematically address the safety and efficacy of topical retinoids for the treatment of ectropion in patients with ichthyosis; however, this case illustrates that topical tazarotene and other retinoids provide a potential treatment option for ectropion in this population. We encourage clinicians to explore medical therapies as alternatives to surgical intervention for the treatment of ectropion in patients with ichthyosis.

Toward a Better Definition of High-Risk Cutaneous Squamous Cell Carcinoma Comment on “Factors Predictive of Recurrence and Death From Cutaneous Squamous Cell Carcinoma” High-Risk Cutaneous Squamous Cell Carcinoma

Zwald F. — Wed, 01 May 2013 00:00:00 GMT

Patient prognosis varies considerably among various types of skin cancer. Approximately 5% of cutaneous squamous cell carcinomas (CSCCs) metastasize, usually to regional nodes. A recent staging system has been developed for CSCC that combines tumor diameter with high-risk features, including primary tumor size greater than 2 cm, Breslow thickness greater than 2 mm, Clark level IV or greater, perineural invasion, poor differentiation, and primary site on the ear or lip, to classify tumors as T1 or T2. These high-risk factors have prognostic significance, particularly among immunocompromised patients. Immunosuppression contributes negatively to the prognosis and outcome of patients with CSCC; however, because strict TNM criteria exclude clinical risk factors in staging, immunosuppression was not included in the staging system.

Update on Metastatic Basal Cell Carcinoma: A Summary of Published Cases From 1981 Through 2011

Wysong A, Aasi SZ, Tang JY. — Wed, 01 May 2013 00:00:00 GMT

While basal cell carcinoma (BCC) is the most common cancer in the United States, metastasis (mBCC) is extremely rare, with an incidence of 0.0028% to 0.55%. The most recent review of mBCC cases from 1894 through 1980 by von Domarus and Stevens is now 30 years old. We conducted a retrospective systematic evaluation of all published mBCC cases from 1981 through 2011 to update patient demographics and tumor characteristics associated with mBCC and to determine whether adjuvant therapy was associated with improved survival.

Use of Sunlight to Treat Dyshidrotic Eczema

Letić M. — Wed, 01 May 2013 00:00:00 GMT

Dyshidrotic eczema is a common complaint. It is very often chronic with recurrences. Although no direct cause of the condition has been identified, immunologic reactions are suggested as a symptom-generating mechanism.

Ustekinumab Therapy for Severe Interstitial Granulomatous Dermatitis With Arthritis

Leloup P, Aubert H, Causse S, et al. — Wed, 01 May 2013 00:00:00 GMT

Interstitial granulomatous dermatitis with arthritis (IGDA) is a rare disease that was first described by Ackerman in 1993. Fewer than 70 cases have been reported in the literature, and specific therapies are not available. We report here a case of severe recalcitrant IGDA that was successfully treated with ustekinumab.