Andrew L. Ondo

Treatment-refractory actinic keratoses successfully treated using simultaneous combination topical 5-fluorouracil cream and imiquimod cream: a case-control study.

BACKGROUND Most actinic keratoses (AKs) respond to standard treatments, but a subset persist and require further intervention. We report a series of 10 patients with AKs that failed to respond to conventional treatment with cryotherapy and topical monotherapy but responded completely to simultaneous therapy with topical 5‐fluorouracil (5‐FU) and imiquimod creams. OBJECTIVE To report the success of this combination therapy in refractory AKs and to determine whether any clinical or histologic features predict for treatment resistance. METHODS Case–control study with two control groups matched to each patient according to lesion location and sex. RESULTS Mean lesion diameter (p < .001), lesion diameter greater than 1 cm (p < .001), and the presence of pain (p = .01) were statistically associated with failure of cryotherapy and topical monotherapy. None of the histologic features evaluated were found to be statistically significant, although thicker epidermis was nearly so (p = .054). CONCLUSIONS In patients who have failed standard therapy for AKs, combination treatment using topical 5‐FU and imiquimod cream may be an effective alternative therapeutic strategy. Larger lesion diameter, specifically greater than 1 cm, and the presence of pain predict conventional treatment resistance.

Primary cutaneous coccidioidomycosis: an incidental finding

A 77-year-old immunocompetent man residing in southern New Mexico presented for a routine skin cancer screening examination. His medical history was significant for several nonmelanoma skin cancers. During the examination, two lesions were found, which were suspected to be basal cell carcinomas (BCCs): a 2.5-mm pink papule on the right chin and a 6 · 8-mm thin pink papule on the left lower back (Fig. 1a). Histological examination of biopsy samples taken from the lesions confirmed the clinical diagnosis of BCC for the right chin papule, but the left lower back lesion had a granulomatous infiltrate in the dermis with spherules diagnostic of coccidioidomycosis (Fig. 1b,c). The patient had been unaware of the lesion on the left lower back until it was identified during the skinscreening examination. After discussing the diagnosis with the patient, he recalled that 5 months earlier he had been working in his yard pruning trees and had sustained a puncture wound from a mesquite branch to the area of concern on his left lower back. After the area had healed, it remained asymptomatic and he forgot about it . He reported that he was currently feeling well and did not recall any flu-like illness or respiratory symptoms at the time of the injury or subsequently. Physical examination found no evidence of local induration, regional adenopathy or evidence of lymphangitis. The patient was referred to a specialist in infectious disease for further evaluation, which revealed no evidence of systemic involvement. Test results included an unremarkable chest X-ray and normal complete blood count, serum electrolytes and liver function tests. Coccidioides antibody complement fixation titre was < 2 (normal range < 2) and antibody immunodiffusion CP D

Irregular Erythematous Nodule on the Upper Arm—Quiz Case

An 11-month-old Hispanic boy was seen for evaluation of severe pruritus. At 4 months of age, he began developing pruritic papules on his trunk and scalp, which often blistered and were noted to be aggravated by heat. Desloratadine, diphenhydramine hydrochloride, topical retapamulin, and topical hydrocortisone butyrate had been prescribed with minimal improvement. His review of systems was remarkable for nearly constant pruritus and chronic, intermittent diarrhea. Physical examination revealed an alert and healthy infant. On his trunk were urticarial papules and plaques, and new lesions could be induced with pressure (Figure 1 and Figure 2). Subtle thickening of his skin was felt over portions of his trunk and proximal extremities. He had no hepatosplenomegaly or lymphadenopathy. A complete blood cell count showed 506 000 μL (506 10/L) platelets, with 6.0% monocytes, 5.1% eosinophils, and 1.7% basophils. An incisional biopsy sample was obtained and sent for histopathologic examination (Figure 3). What is your diagnosis?

Solitary nodule on the thigh

Andrew L. Ondo, MD; Stuart D. Shanler, MD; Jesse Y. Howell; Robert E. Cashman, MD; Clay J. Cockerell, MD; University of New Mexico School of Medicine, Albuquerque, and Las Cruces Dermatology Associates, Las Cruces, New Mexico (Dr Ondo); New Mexico State University, Las Cruces (Mr Howell); and University of Texas Southwestern Medical Center, Dallas (Drs Cashman and Cockerell); Dr Shanler is in private practice in New York, New York