Brook E. Tlougan

Chronic Recurrent Multifocal Osteomyelitis (CRMO) and Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO) Syndrome with Associated Neutrophilic Dermatoses: A Report of Seven Cases and Review of the Literature

Abstract:  A growing body of literature has identified the association between neutrophilic dermatoses and multifocal, aseptic bone lesions in children, termed chronic recurrent multifocal osteomyelitis (CRMO). Classically, patients present with swelling, pain, and impaired mobility of the affected area, with skin lesions developing concurrently or in the future. Bone biopsy reveals inflammatory changes consistent with infectious osteomyelitis, but cultures and histologic staining invariably fail to identify an infectious source. Patients are refractory to antibiotic therapy, but dramatically respond to systemic steroids and may need to be maintained on low‐dose steroids to prevent relapse. Numerous authors have suggested that CRMO and synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome lie along the same clinical spectrum. In fact some believe that CRMO is the pediatric presentation of SAPHO. The two syndromes share numerous characteristics, including osteitis, a unifocal or multifocal presentation, hyperostosis, and pustulosis, which all occur in a generally healthy individual. Our seven patients, five of whom were diagnosed with CRMO, and two of whom were diagnosed with SAPHO syndrome further strengthen the idea that CRMO and SAPHO syndrome do indeed lie along the same clinical spectrum. In addition, we include two rare cases of pediatric Sweet’s syndrome with evidence of pathergy.

Spitz Nevi: Beliefs, Behaviors, and Experiences of Pediatric Dermatologists

IMPORTANCE Controversy exists regarding strategies for diagnosis and management of Spitz nevi, a type of melanocytic neoplasm that most often develops in children. OBJECTIVE To determine the beliefs, behaviors, and experiences of pediatric dermatologists with regard to Spitz nevi. DESIGN Anonymous web-based survey. SETTING Private and academic dermatology practices. PARTICIPANTS Respondents included 175 pediatric dermatologists from the United States and around the world, representing a 51.1% response rate (175 of 342). Analyses were limited to the 144 respondents whose practices included at least 50% children (younger than 18 years). MAIN OUTCOME MEASURES Assessment of the following with regard to Spitz nevi: frequency of diagnosis, general beliefs, techniques used for evaluation (eg, dermoscopy and biopsy), management strategies, and observed outcomes. RESULTS Collectively, respondents had seen approximately 20 000 Spitz nevi; 67.6% (96 of 142) had diagnosed at least 6 Spitz nevi yearly, whereas 90.1% (128 of 142) had diagnosed no more than 2 prepubertal melanomas in the past 5 years. Ninety-six percent of respondents (95.8%; 136 of 142) categorized typical Spitz nevi as benign. Eighty percent of respondents (79.6%; 113 of 142) used dermatoscopy, and 96.5% (137 of 142) avoided partial biopsies of Spitz nevi. In children with a suspected Spitz nevus, clinical follow-up was chosen by 49.3% (69 of 140) of respondents for a small, stable nonpigmented lesion and by 29.7% (41 of 138) for a pigmented lesion with a typical starburst pattern seen via dermatoscopy. Predictors of clinical follow-up of the latter lesion included believing that Spitz nevi are not melanoma precursors (P = .04). Forty-seven percent (62 of 132) of respondents had observed involution of Spitz nevi. No deaths had resulted from the approximately 10 000 Spitz nevi or atypical spitzoid neoplasms seen by the 91 respondents with academic or hospital-based practices. CONCLUSIONS AND RELEVANCE The results of our survey support conservative management of Spitz nevi in children, with clinical follow-up representing an option for typical lesions. This represents an important difference from strategies used for management of these lesions in adults.

Skin Conditions in Figure Skaters, Ice-Hockey Players and Speed Skaters: Part II - Cold-Induced, Infectious and Inflammatory Dermatoses.

Participation in ice-skating sports, particularly figure skating, ice hockey and speed skating, has increased in recent years. Competitive athletes in these sports experience a range of dermatological injuries related to mechanical factors: exposure to cold temperatures, infectious agents and inflammation. Part I of this two part review discussed the mechanical dermatoses affecting ice-skating athletes that result from friction, pressure, and chronic irritation related to athletic equipment and contact with surfaces. Here, in Part II, we review the cold-induced, infectious and inflammatory skin conditions observed in ice-skating athletes. Cold-induced dermatoses experienced by ice-skating athletes result from specific physiological effects of cold exposure on the skin. These conditions include physiological livedo reticularis, chilblains (pernio), Raynaud phenomenon, cold panniculitis, frostnip and frostbite. Frostbite, that is the literal freezing of tissue, occurs with specific symptoms that progress in a stepwise fashion, starting with frostnip. Treatment involves gradual forms of rewarming and the use of friction massages and pain medications as needed. Calcium channel blockers, including nifedipine, are the mainstay of pharmacological therapy for the major nonfreezing cold-induced dermatoses including chilblains and Raynaud phenomenon. Raynaud phenomenon, a vasculopathy involving recurrent vasospasm of the fingers and toes in response to cold, is especially common in figure skaters. Protective clothing and insulation, avoidance of smoking and vasoconstrictive medications, maintaining a dry environment around the skin, cold avoidance when possible as well as certain physical manoeuvres that promote vasodilation are useful preventative measures. Infectious conditions most often seen in ice-skating athletes include tinea pedis, onychomycosis, pitted keratolysis, warts and folliculitis. Awareness, prompt treatment and the use of preventative measures are particularly important in managing such dermatoses that are easily spread from person to person in training facilities. The use of well ventilated footgear and synthetic substances to keep feet dry, as well as wearing sandals in shared facilities and maintaining good personal hygiene are very helpful in preventing transmission. Inflammatory conditions that may be seen in ice-skating athletes include allergic contact dermatitis, palmoplantar eccrine hidradenitis, exercise-induced purpuric eruptions and urticaria. Several materials commonly used in ice hockey and figure skating cause contact dermatitis. Identification of the allergen is essential and patch testing may be required. Exercise-induced purpuric eruptions often occur after exercise, are rarely indicative of a chronic venous disorder or other haematological abnormality and the lesions typically resolve spontaneously. The subtypes of urticaria most commonly seen in athletes are acute forms induced by physical stimuli, such as exercise, temperature, sunlight, water or particular levels of external pressure. Cholinergic urticaria is the most common type of physical urticaria seen in athletes aged 30 years and under. Occasionally, skaters may develop eating disorders and other related behaviours some of which have skin manifestations that are discussed herein. We hope that this comprehensive review will aid sports medicine practitioners, dermatologists and other physicians in the diagnosis and treatment of these dermatoses.

Aquatic sports dermatoses: Part 1. In the Water: Freshwater Dermatoses

The first of this three‐part series on water‐related dermatoses involving the athlete will include sports occurring with the majority of time spent in the water. These sports include swimming, diving, scuba, snorkeling and water polo. Numerous authors have described dermatologic conditions commonly seen in swimmers. This series provides an updated and comprehensive review of these water dermatoses. In order to organize the vast number of skin conditions related to water exposure, we divided the skin conditions into groupings of infectious and organism‐related dermatoses, irritant and allergic dermatoses and miscellaneous dermatoses. The vast majority of skin conditions involving the water athlete result from chemicals and microbes inhabiting each environment. When considering the effects of swimming on one’s skin, it is also useful to differentiate between exposure to freshwater (lakes, ponds and swimming pools) and exposure to saltwater. This review will serve as a guide for dermatologists, sports medicine physicians and other medical practitioners in recognition and treatment of these conditions.

Aquatic sports dematoses. Part 2 - in the water: saltwater dermatoses.

The second part of this three‐part series on water‐related dermatoses will discuss dermatologic conditions seen in athletes exposed to saltwater. The vast majority of the following dermatoses result from contact with organisms that inhabit saltwater, including bacteria, cnidarians, and echinoderms. This review also will include other dermatoses affecting saltwater athletes and should serve as a guide for dermatologists, sports medicine physicians, and other medical practitioners in recognition and treatment of these dermatoses.

Aquatic sports dermatoses: Part 3. On the water.

The third of this three‐part series on water‐related sports dermatoses discusses skin changes seen in athletes who participate in sporting activities on top of or nearby water. While also susceptible to several of the freshwater and saltwater dermatoses discussed in parts one and two of the series, these athletes may present with skin changes unique to their particular sports. This updated and comprehensive review details those near‐water dermatologic conditions commonly seen in sailors, rowers, fishermen, surfers, windsurfers, rafters, and water skiers, and will serve as a guide for dermatologists, sports medicine physicians and other medical practitioners in recognition and treatment of these conditions.

Skin Conditions of Baseball, Cricket, and Softball Players

Each year in the United States over 80 million people participate in bat-and-ball sports, for example baseball and softball. Cricket, the world’s second most popular sport, is enjoyed by hundreds of millions of participants in such countries as India, Pakistan, Australia, New Zealand, Bangladesh, South Africa, West Indies, Sri Lanka, United Kingdom, and Zimbabwe. Although any player can develop skin disease as a result of participation in these bat-and-ball sports, competitive team athletes are especially prone to skin problems related to infection, trauma, allergy, solar exposure, and other causes. These diseases can produce symptoms that hinder individual athletic performance and participation. In this review, we discuss the diagnosis and best-practice management of skin diseases that can develop as a result of participation in baseball, softball, and cricket.

Postoperative pathergic pyoderma gangrenosum after aortic aneurysm repair

with Botox (Allergan, Inc., Irvine, CA, USA). The first patient continues to show good results at six months. The second patient also shows good results but represents a more recent case, and only data for follow-up at three months are available. These patients felt almost no discomfort at the application of the toxin after the use of a cooling device. In these cases, we used an ice roller, a common device used to minimize pain in laser and botulinum toxin applications. We used two units of botulinum toxin type A at each site of intradermal injection. Doses used for injections to the nose can vary. A small study has shown higher doses in the axilla to have prolonged effects. In order to enhance the comfort of patients, we propose the use of cold probes and injection with botulinum toxin type A at nine points only for the treatment of nasal hyperhidrosis. It is possible that EMLA in combination with skin cooling may work better in sensitive patients, but the effects of this combination need to be evaluated in further studies.

Crystal deodorant‐induced axillary granulomatous dermatitis

A healthy 54-year-old Caucasian woman presented with a bilateral axillary eruption for one year. The patient began using a ‘‘natural’’ and unscented crystal deodorant two years before developing skin lesions. Previous medical history was significant for an urticarial reaction to latex. The eruption did not improve after discontinuation of the deodorant or shaving or during treatment with hydrocortisone, topical antifungals, or oral antibiotics. She was not taking any medications. She denied pain, pruritus, fever, or chills. Physical examination revealed monomorphic, red– brown, follicular papules coalescing into plaques in the axillae but was otherwise unremarkable (Fig. 1). A 3 mm punch biopsy of a representative papule revealed well-circumscribed epithelioid granulomatous inflammation within the dermis with multinucleated giant cells and an associated sparse, predominantly lymphocytic infiltrate (Fig. 2). PAS-D, GMS, AFB, and Fite stains failed to reveal microorganisms. Examination under polarized light failed to reveal foreign material. The patient improved using topical tacrolimus within two weeks.

Aquatic Sports Dermatoses: Clinical Presentation and Treatment Guidelines

Aquatic sport dermatoses include a variety of skin conditions that occur in athletes who participate in sporting activities in or on the water. Chemicals and microbes inhabiting the aquatic environment are often responsible for the development of these cutaneous conditions. We review common water sports dermatoses and divide them based on activities that occur in saltwater, freshwater and activities outside the water. Some of the water sports represented in the review include swimming, diving, scuba diving, snorkeling and water polo which are mainly based in the water, as well as sailing, rowing, fishing, surfing, whitewater rafting and water-skiing which are based on the water and outside the water. Aquatic sports dermatoses are presented according to their etiology including infectious and organism-related, contact dermatitis and miscellaneous causes. We also describe conditions specifically associated with water sports including sailing, rowing, fishing and surfing. This comprehensive review focuses on the key recognizable clinical features and principles of management of aquatic sports dermatoses. Our aim is to help sports medicine physicians, dermatologists and other health care providers recognize and treat water sport dermatoses in athletes.