Arash Kimyai-Asadi

Mycophenolate mofetil in autoimmune and inflammatory skin disorders

Mycophenolate mofetil (MMF) has been widely used as an immunosuppressant in organ transplantation. MMF has recently been added to therapeutic regimens for skin disorders. Expanding the use of MMF in dermatology, we describe additional patients with autoimmune and inflammatory skin diseases, including 4 cases of pemphigus vulgaris, 1 case of pemphigus foliaceus, 1 case of perineal and metastatic cutaneous Crohns disease, 1 case of bullous pemphigoid and psoriasis, and 1 case of psoriasis. Most of these patients had refractory disease or had developed significant side effects to conventional therapy, including azathioprine, methotrexate, prednisone, cyclosporine, acitretin, PUVA, UVB, and tacrolimus. MMF was effective and well tolerated in all these patients. The dosages of MMF ranged from 500 mg twice daily (for psoriasis and Crohns disease) to 1250mg twice daily (for 3 of 4 patients with pemphigus vulgaris). MMF is an effective and relatively safe immunosuppressant in autoimmune and inflammatory skin diseases.

Clinical, demographic, and immunohistologic features of vancomycin-induced linear IgA bullous disease of the skin. Report of 2 cases and review of the literature.

Administration of intravenous vancomycin has been associated with the development of linear IgA bullous disease (LABD). In contrast to the idiopathic variant, vancomycin-induced LABD (VILABD) appears to be more transient and to be associated with lower morbidity. The characteristics of this entity remain undefined. Our analysis of clinical, demographic, and immunopathologic features of 2 new and 14 previously reported patients with VILABD reveals that VILABD is clinically and immunopathologically indistinguishable from its idiopathic variant. A variety of premorbid conditions and concomitant medications were observed, none of which was consistently associated with the development of VILABD. VILABD occurs independently of vancomycin trough levels, resolves promptly upon discontinuation of vancomycin, and recurs more severely and with shorter onset latency with vancomycin rechallenge. This entity should be recognized as 1 of the adverse cutaneous effects of intravenous vancomycin, and warrants prompt diagnosis through direct immunofluorescence skin examination.

Fractional photothermolysis: a review and update.

Fractional resurfacing is a new laser treatment modality that creates numerous microscopic thermal injury zones of controlled width, depth, and density that are surrounded by a reservoir of spared epidermal and dermal tissue, allowing for rapid repair of laser-induced thermal injury. This unique modality, if implemented with proper laser-delivery systems, enables high-energy treatments while minimizing risks. In this article, we review the various fractional laser devices, including the new fractional ablative devices, as well as the results of studies on the clinical efficacy of fractional photothermolysis. This technology offers patients significant clinical improvement in photodamage, melasma, and scarring with modest treatment-related downtime and minimal risk of complications.

Adverse Events Associated With Mohs Micrographic Surgery Multicenter Prospective Cohort Study of 20 821 Cases at 23 Centers

IMPORTANCE Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

The 20-Minute Rapid MART-1 Immunostain for Malignant Melanoma Frozen Sections

BACKGROUND Immunohistochemical staining has been used to help detect malignant melanoma on Mohs surgery frozen sections. Previous investigators have developed protocols for reliable MART-1 immunostaining of frozen sections, but these protocols are time-consuming. OBJECTIVE The objective was to report a rapid 20-minute MART-1 immunostaining protocol for frozen sections. METHODS The protocol was utilized on 30 melanomas treated with Mohs micrographic surgery. RESULTS The stain clearly highlighted normal background melanocytes, as well as melanocytic hyperplasia and malignant melanoma. CONCLUSIONS The 20-minute protocol provides a rapid and reliable method for immunostaining of malignant melanoma. The availability of more rapid immunostaining methods improves efficiency of the Mohs laboratory and significantly reduces patient and physician waiting time.

Generalized lupus erythematosus profundus in a patient with genetic partial deficiency of C4

Lupus erythematosus profundus (LEP) is an unusual variant of cutaneous lupus erythematosus (CLE)that is characterized by chronic, recurrent inflammation of the subcutaneous tissue leading to fibrosis. It is found in the settings of both discoid and systemic lupus erythematosus. Generalized forms are extremely rare. We present a case of generalized LEP associated with genetic partial C4-deficiency.

Association Between Number of Stages in Mohs Micrographic Surgery and Surgeon-, Patient-, and Tumor-Specific Features: A Cross-Sectional Study of Practice Patterns of 20 Early- and Mid-Career Mohs Surgeons

OBJECTIVE To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early‐ to mid‐career Mohs surgeons and to assess other factors affecting number of stages. METHODS Statistical analysis of MMS logs of 20 representative early‐ to mid‐career surgeons. RESULTS There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS Early‐ and mid‐career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. &NA; The authors have indicated no significant interest with commercial supporters.

Laser Treatment of Acne Vulgaris

Traditional medical treatments for acne vulgaris include a variety of topical and oral medications. The combination of poor compliance, lack of durable remission, and potential side effects are common drawbacks to these treatments. The use of lasers and light devices has increased dramatically in recent years due to the overall ease of treatment, predictable clinical efficacy, and minimal adverse effects. A variety of light and laser devices has been used for the treatment of acne, including the potassium titanyl phosphate (KTP) laser, the 585- and 595-nm pulsed dye lasers, the 1450-nm diode laser, radiofrequency devices, intense pulsed light sources, low-intensity light treatment, and photodynamic therapy using 5-aminolevulinic acid and indocyanine green. These devices are thought to target underlying pathogenic factors such as Propionibacterium acnes colonization, increased sebaceous gland activity, and the cutaneous inflammatory response. Lasers in particular also have a central role in the management of acne scarring, which tends to be refractory to medical therapies. Fractional photothermolysis, the 1450-nm diode laser, and pulsed dye lasers have been used in the nonablative treatment of acne scars with significant success. In this article, we review the current status of light- and laser-based treatment of acne and related conditions and briefly review the use of lasers for the treatment of acne scarring.

Generalized lupus panniculitis and antiphospholipid syndrome in a patient without complement deficiency

Abstract: Generalized chronic cutaneous lupus including lupus panniculitis in childhood is rare and usually occurs in the setting of genetic complement deficiencies. The association with antiphospholipid syndrome is even more rare. We report a 13‐year‐old girl with extensive lupus panniculitis since the age of 8 months and no evidence of complement deficiency. She recently developed antiphospholipid syndrome characterized by anticardiolipin antibodies and digital necrosis.

Nonablative fractional photothermolysis for facial actinic keratoses: 6-month follow-up with histologic evaluation

BACKGROUND A number of epidermal and papillary dermal skin conditions can be treated safely and effectively with fractional photothermolysis (FP). OBJECTIVE We sought to evaluate the effectiveness of FP with a 1550-nm fractionated erbium-doped fiber laser for the treatment of facial actinic keratoses (AKs). METHODS Fourteen men, ages 59 to 79 years, underwent 5 laser treatments (2- to 4-week intervals) at an energy fluence of 20 to 70 mJ and treatment level of 11 (8-10 passes), corresponding to 32% to 40% surface area coverage. AK counts and photographs were taken at baseline, before each treatment, and at 1-, 3-, and 6-month follow-ups after the last treatment. Biopsies were performed at baseline and at the 3-month follow-up. The clinical improvement of the actinic lesions was evaluated by a dermatologist using digital photography and lesion counts at all 3 follow-up visits. RESULTS The AK count for each patient was reduced on average by 73.1% (67.5%-77.7%) at the 1-month, 66.2% (60.0%-71.5%) at the 3-month, and 55.6% (43.9%-64.8%) at the 6-month follow-up visit. Excluding two cases, all biopsy specimens (baseline and at the 3-month follow-up) were positive for histologic features of AK and/or squamous cell carcinoma. LIMITATIONS This study is limited by a small number of patients; therefore further clinical studies are warranted. CONCLUSIONS FP decreases the number of clinical AKs; however, posttreatment biopsy specimens indicate the histologic persistence of AKs (epidermal tumors). FP is not an adequate single-treatment modality for AKs.