Anna J. Nichols

Association of Human Papillomavirus Vaccine With the Development of Keratinocyte Carcinomas

Importance Keratinocyte carcinomas (KCs), consisting of squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs), are the most common human malignant neoplasms. Several risk factors have been implicated in KC development. For some SCCs, particularly those in immunocompromised patients, human papillomavirus (HPV) may be an important factor. Objective To determine whether quadrivalent HPV vaccination would affect the development of KCs in immunocompetent patients with a history of multiple KCs. Design, Setting, and Participants Two patients with a history of multiple KCs—a man in his 70s (patient 1) and a woman in her 80s (patient 2)—were treated in a private dermatology practice. Each patient received 3 doses of the quadrivalent HPV vaccine at 0, 2, and 6 months in 2013, and both patients underwent full-body skin examinations at least every 3 months. Biopsy-proven skin cancers were recorded for 16 months (for patient 1) or 13 months (for patient 2) after the first dose of vaccine and then compared with the number of biopsy-proven skin cancers recorded over a similar period before the first dose of vaccine. The period of observation was from October 18, 2011, to June 21, 2014. Main Outcomes and Measures The numbers of new SCCs and BCCs after the first dose of the quadrivalent HPV vaccine. Results Patient 1 had a mean of 12 new SCCs and 2.25 new BCCs per year before vaccination. After vaccination, he developed 4.44 SCCs and 0 BCCs per year, a 62.5% reduction in SCCs and a 100% reduction in BCCs. Patient 2 had a mean of 5.5 new SCCs and 0.92 new BCCs per year before vaccination. After vaccination, she developed 1.84 SCCs and 0 BCCs per year, a 66.5% reduction in SCCs and a 100% reduction in BCCs. The quadrivalent HPV vaccine was well tolerated by both patients and had no adverse effects. Conclusions and Relevance A reduction of SCCs and BCCs was observed in 2 patients after administration of the quadrivalent HPV vaccine. These findings highlight the possibility that cutaneous SCC development, and perhaps BCC development, may be driven in part by HPV in immunocompetent patients. Human papillomavirus vaccination may represent an efficacious, cost-effective, readily available, and well-tolerated strategy for preventing KCs.

Phaeohyphomycosis due to Exophiala infections in solid organ transplant recipients: Case report and literature review

This case report and literature review underscores the cutaneous presentations of phaeohyphomycosis in the solid organ transplant population. Increased cognizance with prompt identification is critical. The therapy and clinical outcomes of phaeohyphomycosis, caused by the Exophiala genus, in the solid organ transplant population, is analyzed to examine optimal care. This review highlights the inherent difficulties in providing the appropriate duration of antifungal therapy to avoid relapsing infections in immunosuppressed patients.

The Cutaneous Horn: Fascinating Since 1588

In 1588, Margaret Gryffith captured the attention of many after growing a four-inch horn from her forehead (Figure 1A). According to folklore, Margaret’s husband, just before his death, accused her of “giving him the horn,” a phrase implying that she had been unfaithful. Margaret denied this allegation and countered that a horn would grow from her forehead if she had committed adultery. According to the legend, a horn did grow and suggested to people that this “unworldly horn” was a warning for others to repent their sins and ask God for forgiveness. Margaret was put on display in London, attracting poets and playwrights, who would later document their observations in their writings. These descriptions are thought to be the first written record of a cutaneous horn.

Resolution of Post-Surgical Hypergranulation Tissue with Topical Aluminum Chloride

Hypergranulation is the extension of granulation tissue beyond the required amount to close a tissue defect. We report our experience using aluminum chloride to treat a series of two patients with hypergranulation tissue. Both patients had lengthy treatment courses after Mohs surgery with growth of hypergranulation tissue that resolved once aluminum chloride was placed on the wound. Aluminum chloride is a useful hemostatic agent frequently employed in dermatology. It is a readily available and low-cost option for management of hypergranulation after dermatologic procedures. Chronic wounds are a common treatment challenge for clinicians. Due to its affordability and availability, clinicians may consider topical aluminum chloride when managing post-surgical hypergranulation tissue.

Complementary and Alternative Medicine Therapies for Psoriasis: A Systematic Review.

Importance Up to 51% of patients with psoriasis report the use of complementary and alternative medicine (CAM) in their treatment regimen, although it is unclear which CAM therapies are effective for treatment of psoriasis. Objective This review compiles the evidence on the efficacy of the most studied CAM modalities for treatment of patients with plaque psoriasis and discusses those therapies with the most robust available evidence. Evidence Review PubMed, Embase, and ClinicalTrials.gov searches (1950-2017) were used to identify all documented CAM psoriasis interventions in the literature. The criteria were further refined to focus on those treatments identified in the first step that had the highest level of evidence for plaque psoriasis with more than 1 randomized clinical trial supporting their use. This excluded therapies lacking randomized clinical trial (RCT) data or showing consistent inefficacy. Findings Primary CAM therapy searches identified 457 articles, of which 107 articles were retrieved for closer examination. Of those articles, 54 were excluded because the CAM therapy did not have more than 1 RCT on the subject or showed consistent lack of efficacy. An additional 7 articles were found using references of the included studies, resulting in a total of 44 RCTs (17 double-blind, 13 single-blind, and 14 nonblind), 10 uncontrolled trials, 2 open-label nonrandomized controlled trials, 1 prospective controlled trial, and 3 meta-analyses. Compared with placebo, application of topical indigo naturalis, studied in 5 RCTs with 215 participants, showed significant improvements in the treatment of psoriasis. Treatment with curcumin, examined in 3 RCTs (with a total of 118 participants), 1 nonrandomized controlled study, and 1 uncontrolled study, conferred statistically and clinically significant improvements in psoriasis plaques. Fish oil treatment was evaluated in 20 studies (12 RCTs, 1 open-label nonrandomized controlled trial, and 7 uncontrolled studies); most of the RCTs showed no significant improvement in psoriasis, whereas most of the uncontrolled studies showed benefit when fish oil was used daily. Meditation and guided imagery therapies were studied in 3 single-blind RCTs (with a total of 112 patients) and showed modest efficacy in treatment of psoriasis. One meta-analysis of 13 RCTs examined the association of acupuncture with improvement in psoriasis and showed significant improvement with acupuncture compared with placebo. Conclusions and Relevance The CAM therapies with the most robust evidence of efficacy for treatment of psoriasis are indigo naturalis, curcumin, dietary modification, fish oil, meditation, and acupuncture. This review will aid practitioners in advising patients seeking unconventional approaches for treatment of psoriasis.

Combined Systemic and Intratumoral Administration of Human Papillomavirus Vaccine to Treat Multiple Cutaneous Basaloid Squamous Cell Carcinomas

Importance Squamous cell carcinoma (SCC) is the second most common form of skin cancer, and its incidence is increasing. When surgical management is not an option, finding a safe and efficacious treatment is a challenge. Mounting evidence suggests that the human papillomavirus (HPV) is involved in the pathogenesis of some SCCs. Objective To assess whether the 9-valent HPV vaccine could be an effective treatment strategy for cutaneous SCC. Design, Setting, and Participants A woman in her 90s with multiple, inoperable cutaneous basaloid SCCs was successfully treated at a university-based outpatient dermatology clinic with a combination of systemic and intratumoral delivery of the 9-valent HPV vaccine from March 17, 2016, through February 27, 2017, and then followed up through May 21, 2018. Main Outcomes and Measures Reduction in tumor size and number after a combination of systemic and intratumoral administration of the HPV vaccine. Results All tumors resolved 11 months after the first intratumoral injection of the vaccine. The patient remained free of tumors at the end of follow-up. Conclusions and Relevance This is the first report, to our knowledge, of complete regression of a cutaneous malignant tumor after combined systemic and direct intratumoral injection of the 9-valent HPV vaccine. This report suggests that the HPV vaccine may have therapeutic utility for SCCs in patients who are poor surgical candidates, have multiple lesions, or defer surgery.

Functional Symptoms in Pediatric Dermatology: The Canary in the Coal Mine

The skin is a window into the state of health revealing genetic predispositions, hormonal balance, nutritional status, and internal wellness. It exposes stress burden, emotional well-being, and psychological health. In this way the skin can operate as the metaphorical canary in the coal mine announcing the body’s hidden alarm signals. Psychocutaneous disorders draw attention to the intimate connections between the mind and the skin. During development, the brain and skin are born from the same embryonic tissue and throughout life they continue to be connected through elegant interactions involving neuropeptides, hormones, and inflammatory mediators, the so-called molecules of emotion. Disfiguring skin disease such as vitiligo, acne vulgaris, and ichthyosis have large emotional and psychological interactions. Perhaps surprisingly, the extent of the psychological fallout that results from these conditions is not necessarily related to the objective nature of the disease. Instead it is highly correlated with its subjective severity, which is dependent on self-perception and is highly personal. Recurrent skin disease often results in anxiety, depression, social isolation, body dysmorphic disorder, and dramatic reductions in quality of life rivaling those associated with debilitating systemic illnesses. Crosstalk between the mind and skin also exists wherein physical or psychological stressors can both initiate and worsen skin disease that has clear organic underpinnings such as acne vulgaris, psoriasis, atopic dermatitis, alopecia areata, and cutaneous warts. Primary psychiatric disorders may result in skin and hair conditions such as trichotillomania, psychogenic excoriation, dermatitis artefacta, and delusions of parasitosis. Although mind–skin interactions can cause obstinate symptoms and skin disease, these same connections can also be harnessed for therapeutic benefit.