Donald P. Lookingbill

Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients

BACKGROUND Most previous studies have found that cutaneous metastases occur infrequently and are rarely present at the time the cancer is initially diagnosed. OBJECTIVE We studied patients with metastatic cancer to determine the overall frequency of skin metastases, the frequency that these were the first sign of extranodal disease, and the clinical and histologic features of the cutaneous lesions. METHODS A 10-year period of tumor registry files was searched for patients with metastatic carcinoma and melanoma. For patients with skin metastases, medical records and pathology reports were also examined. RESULTS Of 4020 patients with metastatic disease, 420 (10%) had cutaneous metastases; in 306 of them the skin metastases were the first sign of extranodal metastatic Breast cancer and melanoma were the most common. Nodules were the most frequent clinical presentation, although inflammatory, cicatricial, and bullous lesions were also noted. Incisional metastases were common. Histologic findings most frequently revealed adenocarcinoma that was sometimes suggestive of the site of origin. After recognition of skin metastases, mean patient survival ranged from 1 to 34 months depending on tumor type. CONCLUSION Cutaneous metastases are not uncommon and frequently are the first sign of extranodal metastatic disease, particularly in patients with melanoma, breast cancer, or mucosal cancers of the head and neck.

Tissue production of androgens in women with acne

Precursor and target tissue-produced androgens were measured in the plasma of eighteen women with mild to moderate acne. Mean plasma levels of the precursor androgens (total testosterone, free testosterone, androstenedione, and dehydroepiandrosterone sulfate) wer similar to levels in a group of carefully selected acne-free and hirsute-free, age-matched female controls. In contrast, plasma 3 alpha-androstanediol glucuronide (3 alpha-diol G) values were elevated in 13 of the patients, with a mean value for the entire group nearly threefold that of the normal controls (117 vs 43 ng/dl; p less than 0.001). These results support the concept that target tissue androgen production plays an important hormonal role in the pathogenesis of acne in women and that plasma 3 alpha-diol G may be the most sensitive marker of this process.

Health-related quality of life among patients with facial acne : assessment of a new acne-specific questionnaire

The psychosocial effects of facial acne are well accepted but until recently few validated instruments existed which were suitable for use in clinical trials. The aim of this study was to assess measurement characteristics (reproducibility, correlation with acne severity, and sensitivity to detect change after acne therapy) of a new acne‐specific quality of life instrument, the Acne‐QoL. We found that the Acne‐QoL is reliable, valid and able to distinguish differences across severity groups and improvement over 16 weeks of standard therapy. The use of the Acne‐QoL should aid physicians in understanding the impact of facial acne on young adults, and may be useful in assessing therapeutic effects in acne clinical trials.

Effectiveness of Intravenous Immunoglobulin Therapy for Skin Disease Other Than Toxic Epidermal Necrolysis: A Retrospective Review of Mayo Clinic Experience

OBJECTIVE To examine retrospectively the use and effectiveness of intravenous immunoglobulin (IVIg) treatment of various skin diseases, primarily immunobullous disease. PATIENTS AND METHODS We identified patients who had received IVIg therapy for skin disease between 1996 and 2003 at the Mayo Clinic in Rochester, Minn, Scottsdale, Ariz, and Jacksonville, Fla, and retrospectively reviewed their medical records. RESULTS Eighteen patients were treated with IVIg for various skin diseases: immunobullous disease in 11 adults (pemphigus vulgaris [7 patients], bullous pemphigold [3], and cicatricial pemphigoid [1]); dermatomyositis (2); mixed connective tissue disease (1); chronic urticaria (1); scleromyxedema (1); leukocytoclastic vasculitis (1); and linear IgA bullous disease (1). Responses of patients by type of disease were as follows: pemphigus vulgaris, 1 partial response (PR) and 6 no response (NR); bullous pemphigoid, 1 complete response (CR) and 2 NR; cicatricial pemphigoid, 1 NR; dermatomyositis, 1 CR and 1 PR; mixed connective tissue disease, 1 CR; chronic urticaria, 1 CR; scleromyxedema, 1 CR; leukocytoclastic vasculitis, 1 PR; and linear IgA bullous disease, 1 CR. Six patients (33%) experienced CR, 3 (17%) had PR, and 9 (50%) had NR to IVIg therapy. All 9 nonresponders were adult patients with immunobullous disease. CONCLUSION Although this was a retrospective study of a small cohort of a mixture of patients, the findings emphasize that our experience with IVIg treatment for skin disease, particularly immunobullous disease, is less favorable than that reported previously. Further studies are needed to verify the efficacy of IVIg for skin disease.

A clinical and pathologic study of histiocytosis X in adults

BACKGROUND Histiocytosis X is a neoplastic disorder of Langerhans cells that usually occurs in children. Because histiocytosis X rarely occurs in adults, the diagnosis can frequently be missed by both clinicians and pathologists. OBJECTIVE The purpose of this investigation was to characterize the clinical and pathologic findings of histiocytosis X in adults. METHODS A retrospective study of four adults with histiocytosis X was undertaken. Paraffin-embedded biopsy specimens were stained with a panel of antibodies including S-100, vimentin, Ham-56, leukocyte common antigen, proliferating cell nuclear antigen (PCNA), UCHL-1, CD43, and Ki-1. RESULTS The predominant lesions were papules and pustules that usually involved the groin, axilla, and scalp. Histologically the infiltrate exhibited a periappendageal distribution. Strong positive staining for PCNA appeared to correlate with the clinical course. CONCLUSION Histiocytosis X in adults has a predilection for skin sites rich in appendages and histologically shows a periappendageal infiltrate. PCNA staining of the histiocytes may indicate progressive disease and serve as a useful prognostic marker.

Recalcitrant plantar warts treated with recombinant quadrivalent human papillomavirus vaccine

To the Editor: A 59-year-old healthy woman presented in October 2009 with a 5-year history of recalcitrant plantar warts. Four large warts were present on her feet; the largest measured 4.6 cm in diameter. She had previously been treated with numerous therapies, including liquid nitrogen cryotherapy, topical imiquimod 5%, 40% salicylic acid, pulsed dye laser, and oral cimetidine without improvement. A shave biopsy was performed and findings confirmed the diagnosis. On the basis of the classic clinical and histopathologic findings, human papillomavirus (HPV) typing was not performed initially. Treatment was initiated with aggressive liquid nitrogen cryotherapy in conjunction with topical tretinoin 0.025% with the plaques occluded by 40% salicylic acid tape for several weeks without improvement. Subsequently, a series of 12 intralesional bleomycin 1% injections were administered approximately every 2 weeks. Minimal improvement was observed; the largest wart still measured 4 cm after the final injection (Fig 1, A). On the basis of isolated literature reports of crossprotection of the quadrivalent HPV vaccination types 6, 11, 16, and 18, this vaccine was administered in the patient’s arm in 3 doses at 0, 2, and 6months (July 2010, September 2010, and January 2011, respectively). Other treatments were discontinued at that time for lack of efficacy. When the patient returned for follow-up in November 2010, the largest wart had decreased in size and thickness, measuring 2.5 cm. By February 2011, only 2 warts remained, the largest measuring 0.5 cm in diameter. By April 2011, the warts had completely regressed (Fig 1, B). Given the patient’s response to the vaccination, HPV in situ hybridization studies were performed on paraffin-embedded tissue sections from theoriginal biopsy specimen.Theywere negative forHPV types 6, 11, 16, and18but positive for a general probe forHPV. In July 2011, the patient’s feet remained wart free with no evidence of recurrence. Human papillomavirus is associated with cutaneous and genital warts, precancerous dysplasia, and cervical cancer. Prophylactic quadrivalent HPV vaccine (types 6, 11, 16, and 18) has been proven effective in preventing HPV-associated precancerous and cancerous lesions. Vaccination has also been shown to be an effective treatment for high-grade

Ciclopirox gel for seborrheic dermatitis of the scalp

Background  Seborrheic dermatitis is a common inflammatory skin disorder that usually occurs in patients with pre‐existing seborrhea. The etiology of seborrheic dermatitis is uncertain. Typically, sites dense with sebaceous glands support growth of the lipophilic yeast Malassezia furfur. Ciclopirox (Loprox®) gel is a hydroxypyridone, broad‐spectrum antifungal agent proven effective against the yeast M. furfur.

Ciclopirox gel in the treatment of patients with interdigital tinea pedis

Background  Tinea pedis (athlete’s foot) is the most common fungal infection in the general population. Ciclopirox, a broad‐spectrum hydroxypyridone antifungal, has proven efficacy against the organisms commonly implicated in tinea pedis: Trichophyton rubrum, T. mentagrophytes and Epidermophyton floccosum.

Extensive erosions and pustular lesions of the scalp--quiz case.

A 32-year-old morbidly obese man (316 kg, body mass index, 102.7 [calculated as weight in kilograms divided by height in meters squared]) with no medical history presented with a 2-year history of 2 progressively enlarging tumors on his bilateral thighs. These tumors were asymptomatic, but they greatly interfered with ambulation. Physical examination revealed 2 pedunculated, oblong, soft, nontender subcutaneous tumors (Figure 1). The tumors grew from the distal right and proximal left thighs and measured 30 4 5 cm and 102 30 50 cm, respectively. The overlying skin was extremely edematous with several shallow pressure ulcerations. Focal lichenification and erythema were present on the larger tumor, reflecting chronic rubbing on the ground while walking. An intraoperative incisional biopsy specimen of the larger tumor was sent for histologic examination (Figure 2 and Figure 3). Ultrasonography demonstrated fatty tissue, edema, and minimal flow throughout the tumors. What is your diagnosis?