Barry Ladizinski

Update on necrobiosis lipoidica: A review of etiology, diagnosis, and treatment options

Necrobiosis lipoidica (NL) is a rare chronic granulomatous disease that has historically been associated with diabetes mellitus. Debate exists regarding the etiology and pathogenesis of NL with a widely accepted theory that microangiopathy plays a significant role. NL typically presents clinically as erythematous papules on the front of the lower extremities that can coalesce to form atrophic telangiectatic plaques. NL is usually a clinical diagnosis, but if the clinical suspicion is uncertain, skin biopsy specimen can help differentiate it from sarcoidosis, necrobiotic xanthogranuloma, and granuloma annulare. NL is a difficult disease to manage despite a large armamentarium of treatment options that include topical and intralesional corticosteroids, immunomodulators, biologics, platelet inhibitors, phototherapy, and surgery. Randomized control trials are lacking to evaluate the many treatment methods and establish a standard regimen of care. Disease complications such as ulceration are common, and lesions should also be monitored for transition to squamous cell carcinoma, a less common sequelae.

Mucocutaneous manifestations of helminth infections: Nematodes

In the 21st century, despite increased globalization through international travel for business, medical volunteerism, pleasure, and immigration/refugees into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on the cutaneous manifestations of helminth infections and is divided into 2 parts: part I focuses on nematode infections, and part II focuses on trematode and cestode infections. This review highlights the clinical manifestations, transmission, diagnosis, and treatment of helminth infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

Wax On, Wax Off: Pubic Hair Grooming and Potential Complications

Pubichairgrooming isbecomingan increasinglycommonpracticeamong women of all societies and demographic groups. In the United States, womenaremore likely togroomfor reasons that are sexuallydrivenand aremore likely to stopgroomingwhen lacking a current sexual partner. Further, pubic hair removal is significantly associated with a greater interest in sex and having a casual sex partner. Waxing is apopularepilation technique forpubichair removal,which involves applying hot wax to an area of skin that is then covered with muslin. The muslin is quickly removed, extracting the wax and unwanted hairs from the pubic area. Although relatively safe, waxing can cause microtrauma to the skin and its underlying structures with reported complications that include folliculitis, local spread of infection, burns, and syringoma development. Waxing-inducedfolliculitisofthepubicarea isacommoncomplication, usually secondary to infectionwithStaphylococcusaureus,Streptococcus pyogenes, orPseudomonasaeruginosa. The sourceof infectionmaybe normalskin flora,autoinoculation,contaminationofwaxingtools,orcolonizationof the individualperformingtheprocedure.Other infectionscan occur, andone reportdescribedawomanwithpoorly controlled insulindependent diabetesmellituswhodevelopedherpes simplex virus reactivationandsubsequentgroupAstreptococcustoxicshocksyndromefollowinga“Brazilian”bikiniwax.Anotherreportdescribedthedevelopment ofsyringomas in thegroin regionofa31-year-oldman,whichwasthought to be an inflammatory, hyperplastic response to repetitivewaxing. Pubichairwaxingcanalsocauseburns,withmostbeingsuperficialorpartialthicknessburns.Severeburnsrequiringdebridementandsplit skingrafting have been described following the use of self–waxing kits. Waxingcausesdeficits in themucocutaneousbarrier thatmaybesufficient for viral entry and transmission, potentially increasing the risk of acquiring sexually transmitted infections (STIs). One study demonstrated a correlation between sexually transmitted molluscum contagiosumand theuseof pubic hair removal practices. Still, there is a paucityofdataregardingtransmissionofotherviralagents, likelycomplicated bytheasymptomaticgenital sheddingofherpessimplexvirusesand long latency periods of human papillomaviruses. Becauseof itspopularity, healthpractitioners shouldbeawareof the potential dermatologic and systemic complications associatedwithpubic hairwaxing.While it has been shown that pubic hairwaxing directly correlates with increased sexual prevalence, more studies are necessary to further elucidate the risk of STI transmission after waxing. Individualswhowax their pubic hair shouldbe informedof this possible risk and perhaps be advised to abstain from sexual activity for a certain period of time after waxing.

Krokodil: From Russia With Love

51. Cavet J, Dickinson AM, Norden J, Taylor PR, Jackson GH, Middleton PG. Interferon-gamma and interleukin-6 gene polymorphisms associate with graft-versus-host disease in HLA-matched sibling bone marrow transplantation. Blood. 2001;98(5): 1594-1600. 52. Singh A, Sharma P, Kar HK, et al; Indian Genome Variation Consortium. HLA alleles and amino-acid signatures of the peptide-binding pockets of HLA molecules in vitiligo. J Invest Dermatol. 2012;132(1):124-134.

The human skin microbiome

We generally think of bacteria, fungi, and viruses as pathogens – foreign invaders seeking to harm us. In fact, pathogens are a minority among all of the microbes that populate the Human Microbiome (HM), a term proposed by the well-known geneticist, Joshua Lederberg. By using the term, Human Microbiome, he was referring to all those microbes that are found in and on human beings. Most of these microbes are not only harmless but are in fact beneficial, both in terms of our normal bodily functions as well as protection from other pathogenic microbes. There are several interesting points to consider about the HM. First, the bacteria in our microbiome outnumber us! It is estimated that 100 trillion bacteria live in and on our bodies. Further, only 1% of the cells on our person are human and the other 99% are microbes. To put it graphically, half of our stool is not leftover food but rather microbial biomass. This constitutes 2–5 pounds of bacteria produced by our body each day. David Relman’s opinion is that “We are like coral, an assemblage of life forms living together.” We know that bacteria can harm us. But, do microbes benefit us as well? Consider, for the moment, the use of antibiotics. Besides destroying pathogenic bacteria, antibiotics may disturb the delicate balance of commensals that contribute to our homeostasis. For example, an overgrowth of toxin-producing Clostridium difficile can cause pseudomembranous colitis. What is really impressive, however, is the response to fecal microbial transplants (presumably filled with normal microbe flora) for the treatment of C. difficile colitis refractory to conventional antibiotic therapy. In this case, our health may be more efficiently restored by infusing bacteria, not by infusing additional antibiotics. Significant evidence exists regarding the health benefits of diverse gut flora. By creating free fatty acids and thus lowering the pH of the skin surface, Propionibacterium acnes contributes to making the skin inhospitable for pathogens such as Staphylococcus aureus and Streptococcus pyogenes but allows less virulent coagulase-negative Staphylococcus and Corynebacterium to flourish. In turn, many strains of Staphylococcus epidermidis produce antimicrobial peptides that limit the growth of other microbes on the skin. Pseudomonas aeruginosa, a common skin flora, is well known for producing multiple antimicrobial peptides, including mupirocin. This peptide has been reproduced for topical use as an agent against gram-positive bacteria, including methicillin-resistant S. aureus. The importance of flora on the skin is not limited to its direct effect on other pathogens; there is evidence that the presence of skin commensals, such as Staphylococcus epidermidis, may help prime the immune system and enhance innate immunity. How did we learn about the HM? It was not from the culturing of bacteria from various orifices, as only 1% of the HM can grow in synthetic laboratory, but rather

Vanishing Lung Syndrome

A 41-year-old man with a smoking history of 30 pack-years presented with chronic chest pain, dyspnea, and cough. Physical examination revealed cachexia, with decreased apical breath sounds and hyperresonance to percussion in both lungs.

Mucocutaneous manifestations of illicit drug use.

Millions of individuals worldwide are active users of illicit drugs and novel synthetic substances. Compared with non-drug users, individuals using illicit substances have higher rates of health services utilization and increased medical care costs. Illicit drug users are at increased risk for skin and soft tissue infections, sexually transmitted infections and other blood-borne infections (e.g. viral hepatitis and human immunodeficiency virus [HIV]), secondary to use of shared needles or paraphernalia, decreased sexual inhibition, and engagement in high-risk sexual encounters. Common skin markers of drug abuse include excoriations secondary to formication (the sensation of insects crawling on the skin), infections, ulcerations, and scarring. Dermatologists may encounter these patients and should be familiar with the slang names and skin findings of commonly used illicit drugs (Tables 1 and 2). We present a concise review of the dermatologic complications associated with illicit drug use and hope this review will raise awareness of both old and new drugs of abuse. Classic drugs of abuse: cocaine, heroin and methamphetamine

Indoor Tanning Amongst Young Adults: Time to Stop Sleeping on the Banning of Sunbeds

Since the industrial revolution, “a tan” has been a status symbol of wealth and leisure in many countries. Tanning beds expose the skin to ultraviolet radiation (UVR) sufficient to cause keratinocyte DNA damage and to induce production of melanin—a pigment that absorbs ultraviolet (UV) light. Tanning salons have served as a quick, convenient and inexpensive way to attain this “healthy, wealthy look.” As such, indoor tanning has become a big business in the United States, with over 50,000 indoor tanning facilities generating annual revenues of over

A Nodular Protuberance on the Hard Palate

5 billion USD. The association between tanning and skin cancer (both melanoma and non-melanoma) in adulthood has been well established, especially amongst individuals with early childhood and adolescent exposure. Increasingly, tanning is being outlawed for minors, with the California legislature leading the way in January 2012. Similar to smoking cessation counseling and therapy, adult medicine physicians have a unique opportunity to discourage tanning bed use, acting to prevent irreparable DNA damage to the skin prior to the development of skin cancers. In this comment, we provide an update on the epidemiology of tanning bed use and its association with skin cancers, the opioid-like effects of tanning, pending tanning-related legislation and special interests, and close with clinical pearls for addressing this issue with patients.

The Coffee Bean Sign and Sigmoid Volvulus in an Elderly Adult

A 66-year-old man presents with a slowly enlarging growth in his mouth that appeared more than 20 years ago. He denies pain and discomfort but is concerned because the mass has increased in size during the past year. He does not wear dentures and denies trauma, use of tobacco products, poor nutrition, and risky sexual practices. Family history is noncontributory. Physical examination reveals a healthy appearing male with a nontender, symmetric, nodular bony protuberance on the midline of the hard palate. Two prominent protuberances are also noted at the bilateral maxillary tuberosities (Figure). The remainder of the examination is unremarkable. Quiz at jama.com Figure.