Arturo R. Dominguez

Calciphylaxis: Controversies in Pathogenesis, Diagnosis and Treatment.

ABSTRACT Calcific uremic arteriolopathy, otherwise known as calciphylaxis, is a rare disease characterized by skin ulceration and tissue necrosis, likely the result of vascular calcification with accompanying intimal hypertrophy and small vessel thrombosis. Although most often associated with end‐stage renal disease, it has also been seen in a number of other disorders (collectively referred to as nonuremic calciphylaxis). The purpose of this review is to summarize and analyze the currently available literature regarding the pathophysiology, risk factors, clinical presentation, diagnostic features and treatment modalities for this exceptionally uncommon illness. A series of recommended treatments is proposed for optimal treatment of calciphylaxis lesions.

Hidradenitis Suppurativa, Eruptive Melanocytic Nevi, and Keratosis Pilaris-like Eruption in a Patient Treated With Vemurafenib

reportedusingcryotherapy, 5 wereportthiscasetoemphasizetheimportanceofrecognizingCAHandpursuingtreatmentowingtothepotentialforpremalignantchange.Furthermore,thesuccessofcryotherapysupportstheconcept that this condition may be due to an abnormal proliferation of keratinocytes. Presumably, cryotherapy may destroy the abnormal keratinocytes and allow for repopulation with normal epidermal cells, thereby eliminating the potential for malignant transformation in the future. This case demonstrates that cryotherapy is an efficacioustherapeuticoptionthatshouldbeconsideredforthe treatment of CAH. Furthermore it may eliminate the potential for progression to more serious cutaneous disease.

Pyoderma gangrenosum (PG) associated with levamisole-adulterated cocaine: Clinical, serologic, and histopathologic findings in a cohort of patients.

BACKGROUND Recently, isolated reports of pyoderma gangrenosum (PG) secondary to levamisole-contaminated cocaine have been described, with similar serologic findings to the vasculopathic presentation. OBJECTIVE We sought to describe clinical, histopathological, and serologic findings in 8 patients with PG associated with levamisole-contaminated cocaine. METHODS Eight consecutive patients presenting with this disease spanning the period from 2011 to 2015 were included for the cohort. Observed variables included: lesion distribution, morphology, serologic titers, and histopathologic evaluation for vasculitis and vasculopathy. RESULTS All patients reported cocaine exposure prior to the onset of lesions resembling PG. Lesions appeared primarily on the upper (6 of 8 patients) and lower (all 8 patients) extremities. Most patients demonstrated elevated titers for p-ANCA and antiphospholipid antibodies, and a diffuse dermal infiltrate dominated by neutrophils was seen in all biopsy specimens. Lesions improved or remained stable with conservative management or short courses of steroids, and recurrence was only noted on re-exposure to adulterated cocaine. LIMITATIONS The study is limited by sample size. CONCLUSIONS PG may occur after exposure to levamisole-adulterated cocaine. Clinical and histopathological findings resemble those seen in conventional forms of PG, whereas serologic findings mirror those seen in other levamisole-associated vasculopathic or vasculitic eruptions. Cocaine avoidance represents a cornerstone of management in these patients.

Nonuremic calciphylaxis in a patient with rheumatoid arthritis and osteoporosis treated with teriparatide

REFERENCES 1. Moschos SJ, Edington HD, Land SR, Rao UN, Jukic D, Shipe-Spotloe J, et al. Neoadjuvant treatment of regional stage IIIB melanoma with high-dose interferon alfa-2b induces objective tumor regression in association with modulation of tumor infiltrating host cellular immune responses. J Clin Oncol 2006;24:3164-71. 2. Food and Drug Administration. Vemurafenib. Available from: http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedical ProductsandTobacco/CDER/ucm268301.htm. Accessed October 30, 2013. 3. Chapman PB, Hauschild A, Robert C, Haanen JB, Ascierto P, Larkin J, et al; , BRIM-3 Study Group. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med 2011;364:2507-16. 4. Kolar GR, Miller-Thomas MM, Schmidt RE, Simpson JR, Rich KM, Linette GP. Neoadjuvant treatment of a solitary melanoma brain metastasis with vemurafenib. J Clin Oncol 2013;31:e40-3. 5. Fadaki N, Cardona-Huerta S, Martineau L, Thummala S, Cheng ST, Bunker SR, et al. Inoperable bulky melanoma responds to neoadjuvant therapy with vemurafenib. BMJ Case Rep 2012: bcr2012007034.

Need for More Education for Latinos Regarding Sun-Safe Behaviors

Comprising 15% of the US population and growing faster than any other ethnic category, Latinosareexperiencinganincreasingincidenceof melanoma. Individuals with high socioeconomic status (SES) account for more than 50% of all melanoma cases among non-Latino whites (NLWs); however, individuals with low SES account for the largest number of melanoma cases among Latinos. 1 Thus, a need exists for effectiveprimarypreventionpublichealthprogramstargeted to Latinos with low SES. The failure of dermatologists to recognize the role of acculturation in the sun-safe behaviors of Latinos constitutes a practice gap. Acculturation, defined as the acquisition or adoption of the cultural elements of the dominant society (such as language[s], food, clothing, music, and sports), has a positive effect on sunscreen use but negative effects on sun avoidance and use of sun-protective clothing, according to the article by Andreevaetal 2 inthisissueoftheArchives.Also,theeffect of acculturation on sunscreen use was shown to be mediated through current membership in various social networks, self-perceived health status, and educational level. Previous studies 1,3 have shown that leisure outdoor activities increase with acculturation, but lessacculturatedindividualsaremorelikelytoexperienceoccupational sun exposure from outdoor agricultural and manual labor. Because the frequency of day-to-day sun exposure is likely to be similar to that of NLWs, Latinos with high levels of acculturation may respond favorably to strategies previously used in NLWs. A public health gap has been identified in 2 crucial areas:providingculturallysensitiveinformationinSpanish and English to Latinos of each SES and with all levels of acculturation and expanding beyond the traditional sources for health care education (including the media) to include Latino-specific social networks. Lessacculturated patients are likely to have limited literacy in Spanish and English, to have limited conversational ability in English, and to have immigrated to the United States recently, all of which tend to result in poor access to and knowledge of US health care systems. Given the importance of social networks to sun-safe behaviors, dermatologists should increase efforts to provide education to outdoor agricultural and manual laborers, as well as the family members and friends who comprise their social networks. Interventions to increasesun-safebehaviorsinless-acculturatedLatinosare likely to have a significant effect when culture-specific educational materials and programming such as fotonovelas (ie, graphic novels) and health-themed educational theater presentations are provided in Spanish and English, particularly in contexts such as Latino health fairs. Research into the use ofpromotoras de salud(ie, lay health care workers) should be performed in dermatology because such workers have been shown to improve medicaloutcomesinLatinos. 4 CollaborationbetweendermatologistsandlocalLatinohealthcareorganizationsalso should be encouraged. Barriers include lack of awareness by dermatologists regarding the importance of promoting sun-safe behaviors in Latinos; lack of published research regarding the interplaybetweenacculturation,SES,andFitzpatrickskin type; lack of centers of dermatology with research experience in patients with ethnicity other than NLW; lack ofeducationinmedical-Spanishterminologyamongdermatologists; and lack of US-born Latino dermatologists who could serve as leaders and advocates in closing this practice gap.

Bedside diagnostics in dermatology: Parasitic and noninfectious diseases

In addition to aiding the diagnosis of viral, bacterial, and fungal diseases, mineral oil preparation, Tzanck smear, and other techniques can be used to diagnose parasitic infections, neonatal pustular dermatoses, blistering diseases, Stevens-Johnson syndrome, and a plethora of other benign and malignant conditions, including granulomatous diseases and tumors. In many cases, these techniques are specific, reliable, and easy to perform and interpret. In others, a certain amount of training and expertise are required. In the proper clinical scenario, these tests are rapid, economical, and compare favorably with other diagnostic methods.

Creation of an internal teledermatology store-and-forward system in an existing electronic health record: A pilot study in a safety-net public health and hospital system

Importance External store-and-forward (SAF) teledermatology systems operate separately from the primary health record and have many limitations, including care fragmentation, inadequate communication among clinicians, and privacy and security concerns, among others. Development of internal SAF workflows within existing electronic health records (EHRs) should be the standard for large health care organizations for delivering high-quality dermatologic care, improving access, and capturing other telemedicine benchmark data. Epic EHR software (Epic Systems Corporation) is currently one of the most widely used EHR system in the United States, and development of a successful SAF workflow within it is needed. Objectives To develop an SAF teledermatology workflow within the Epic system, the existing EHR system of Parkland Health and Hospital System (Dallas, Texas), assess its effectiveness in improving access to care, and validate its reliability; and to evaluate the system’s ability to capture meaningful outcomes. Design, Setting, and Participants Electronic consults were independently evaluated by 2 board-certified dermatologists, who provided diagnoses and treatment plans to primary care physicians (PCPs). Results were compared with in-person referrals from May to December 2013 from the same clinic (a community outpatient clinic in a safety-net public hospital system). Patients were those 18 years or older with dermatologic complaints who would have otherwise been referred to dermatology clinic. Main Outcomes and Measures Median time to evaluation; percentage of patients evaluated by a dermatologist through either teledermatology or in-person compared with the previous year. Results Seventy-nine teledermatology consults were placed by 6 PCPs from an outpatient clinic between May and December 2014; 57 (74%) were female and their mean (SD) age was 47.0 (12.4) years. Teledermatology reduced median time to evaluation from 70.0 days (interquartile range [IQR], 33.25-83.0 days) to 0.5 days (IQR, 0.172-0.94 days) and median time to treatment from 73.5 to 3.0 days compared with in-person dermatology visits. Overall, a greater percentage of patients (120 of 144 [83.3%]) were evaluated by a dermatologist through either teledermatology or in-person during the 2014 study period compared with the previous year (111 of 173 [64.2%]). Primary care physicians followed management recommendations 93% of the time. Conclusions and Relevance Epic-based SAF teledermatology can improve access to dermatologic care in a public safety-net hospital setting. We hope that the system will serve as a model for other health care organizations wanting to create SAF teledermatology workflows within the Epic EHR system.

Rituximab in the treatment of 38 patients with Pemphigus with long-term follow-up

References 1 Nakamura Y, Fujisawa Y, Teramoto Y et al. Tumor-to-bone distance of invasive subungual melanoma: an analysis of 30 cases. J Dermatol 2014; 41: 872–877. 2 Izumi M, Ohara K, Hoashi T et al. Subungual melanoma: histological examination of 50 cases from early stage to bone invasion. J Dermatol 2008; 35: 695–703. 3 Kleinerman R, Kriegel D, Amir I, Emanuel PO, Markinson BC. Osteoinvasive subungual melanoma: a case and review. J Drug Dermatol 2010; 9: 159–163. 4 Maekawa T, Komine M, Murata S, Ohtsuki M. Surgical treatment of subungual melanoma: a cases treated with bone splitting of the distal phalanx. J Dermatol 2014; 41: 944–946. 5 Gregorcyk S, Shelton RM, Ladaga LE, Perry RR. Pathologic fracture secondary to subungual melanoma. J Surg Oncol 1996; 61: 230–233. 6 Shin HT, Jang KT, Mun GH, Lee DY, Lee JB. Histopathological analysis of the progression pattern of subungual melanoma: late tendency of dermal invasion in the nail matrix area. Mod Pathol 2014; 27: 1461–1467. 7 Sureda N, Phan A, Poulalhon N, Balme B, Dalle S, Thomas L. Conservative surgical management of subungual (matrix derived) melanoma: report of seven cases and literature review. Br J Dermatol 2011; 165: 852–858.

Bedside diagnostics in dermatology: Viral, bacterial, and fungal infections

Viral, bacterial, and fungal infections are frequently encountered in clinical practice, resulting in numerous cutaneous manifestations. Although diagnosis of these infections has changed over time because of technological advancements, such as polymerase chain reaction, bedside diagnostic techniques still play an important role in diagnosis and management, enabling rapid and low-cost diagnosis and implementation of appropriate therapies. This 2-part article will review both common and infrequent uses of bedside diagnostic techniques that dermatologists can incorporate into daily practice. This article examines the utility of bedside tests for the diagnosis of viral, bacterial, and fungal infections. The second article in this series reviews the use of bedside diagnostics for parasitic and noninfectious disorders.

Systemic lupus erythematosus in a patient with PTEN hamartoma tumour syndrome

nercept pre-dating that of adalimumab, rather than a reflection of tolerance itself. Ustekinumab appeared to be effective after failure of other anti-tumour necrosis factor a agents, although this study is limited due to the small numbers involved making it difficult to make any definitive conclusions. Studies from clinical practice are needed to inform guidance while awaiting information from national databases such as the British Association of Dermatologists Biologic Interventions Register. Clarification of national guidance on switching biological agents would make the securing of funding for patients in need of these effective therapies less open to interpretation and more geographically consistent.