Eric W. Hossler

Gastric bypass surgery improves psoriasis

Recent studies have found that psoriasis is linked to a higher rate of obesity, and that obesity itself is a risk factor for the development of psoriasis. There are two recent reports of chronic severe psoriasis improving with weight loss after Roux-en-Y gastric bypass surgery. We have observed two patients with body mass indices greater than 50 kg/m(2) who had marked improvement in their psoriasis after gastric bypass surgery. The common link between psoriasis and obesity may be a state of chronic inflammation, including elevated levels of T helper 1 (TH-1) cytokines such as tumor necrosis factor. More recent research has shown that the appetite suppressant leptin is also elevated in patients with psoriasis and obesity, and that levels decrease with weight loss. We conclude that weight loss may be a useful adjunctive therapy for obese patients with psoriasis.

Caterpillars and moths: Part II. Dermatologic manifestations of encounters with Lepidoptera

Caterpillars are the larval forms of moths and butterflies and belong to the order Lepidoptera. Caterpillars, and occasionally moths, have evolved defense mechanisms, including irritating hairs, spines, venoms, and toxins that may cause human disease. The pathologic mechanisms underlying reactions to Lepidoptera are poorly understood. Lepidoptera are uncommonly recognized causes of localized stings, eczematous or papular dermatitis, and urticaria. Part I of this two-part series on caterpillars and moths reviews Lepidopteran life cycles, terminology, and the epidemiology of caterpillar and moth envenomation. It also reviews the known pathomechanisms of disease caused by Lepidopteran exposures and how they relate to diagnosis and management. Part II discusses the specific clinical patterns caused by Lepidopteran exposures, with particular emphasis on groups of caterpillars and moths that cause a similar pattern of disease. It also discusses current therapeutic options regarding each pattern of disease.

Caterpillars and moths

Lepidoptera (moths, butterflies, and caterpillars) are an uncommon cause of adverse reactions in humans. Most reactions to Lepidoptera are mild and self‐limited; however, reactions in sensitive individuals and reactions to particular species can be severe and life threatening. Specific syndromes caused by Lepidoptera include erucism (cutaneous reactions from contact with caterpillars, moths, or cocoons), lepidopterism (systemic involvement), ophthalmia nodosa (ocular involvement), dendrolimiasis and pararamose (each with joint symptoms relating to a specific species of caterpillar), lonomism (a severe hemorrhagic disease related to Lonomia species), and seasonal ataxia (related to ingestion of Anaphe venata). In most cases, reactions to Lepidoptera can be treated symptomatically with prompt removal of offending hairs. Antipruritic or anesthetic topical preparations, topical steroids, and oral antihistamines are often used. In the case of potentially fatal Lonomia envenomation, an effective antivenin has been manufactured.

Cutaneous lepidopterism: dermatitis from contact with moths of Hylesia metabus (Cramer 1775) (Lepidoptera: Saturniidae), the causative agent of caripito itch

Background  Lepidopterism derived from contact with arthropods and/or their products can result in adverse reactions that vary in severity from mild irritation to severe reactions including anaphylactic shock and death. Lepidopterism includes cutaneous and/or mucosal manifestations, systemic symptoms, or both mucocutaneous and systemic manifestations.

Asymptomatic facial papules

Jih MH, Friedman PM, Kimyai-Asadi A, Friedman ES, Hymes SR, Goldberg LH. Lupus miliaris disseminatus faciei: treatment with the 1450-nm diode laser. Arch Dermatol 2005;141:143-5. Khokhar O, Khachemoune A. A case of granulomatous rosacea: sorting granulomatous rosacea from other granulomatous diseases that affect the face. Dermatol Online J 2004;10:6. van de Scheur MR, van der Waal RI, Starink TM. Lupus miliaris disseminatus faciei: a distinctive rosacea-like syndrome and not a granulomatous formof rosacea.Dermatology2003;206:120-3.

Secondary syphilis and suspected child abuse

A 38-year-old Hispanic woman presented with a widespread papulosquamous eruption with accentuation on the palms and soles (Fig 1, A). Travel history was remarkable for a recent trip to her native country (Dominican Republic). Her 13-year-old son, who accompanied her on the trip, developed a similar rash after their return (Fig 1, B). In addition, the patient noted that her boyfriend, whom she was visiting in the Dominican Republic, had a rash when she arrived. The rapid plasma reagin (RPR) test produced negative findings whereas the skin biopsy specimen from the patient’s foot showed a psoriasiform lichenoid dermatitis teeming with spirochetes highlighted by a Steiner stain. After discussion with the laboratory about the RPR results, serial dilutions proved positive (prozone effect). At follow-up 4 days later, the son was evaluated for his rash. As expected, the patient’s fluorescent treponemal antibody absorption (FTA-ABS) test result was positive, but the son’s test finding was only minimally reactive.

Efficacy of curettage alone for invasive cutaneous squamous cell carcinoma: A retrospective cohort study

Sidedness Left 433/900 (48.1) .26 160/332 (48.2) 263/551 (47.7) .89 277/559 (49.6) 154/339 (45.4) .23 Right 467/900 (51.9) 172/332 (51.8) 288/551 (52.3) 282/559 (50.4) 185/339 (54.6) Anatomic locationy Area Hz1 614/1009 (60.9) 247/383 (64.5) 353/608 (58.1) 364/621 (58.6) 250/386 (64.8) Area Mx1 293/1009 (29) .00 96/383 (25.1) 193/608 (31.7) .07 194/621 (31.2) 97/386 (25.1) .10 Area Lk1 102/1009 (10.1) 40/383 (10.4) 62/108 (10.2) 63/621 (10.1) 39/386 (10.1) Cancer type{# BCC 748 (72.3) 274/392 (69.9) 461 (73.9) 441/639 (69) 306/394 (77.7) SCC 275 (16.9) .00 70/392 (17.9) 101 (16.2) .44 131/639 (20.5) 44/394 (11.2) .00 SCC in situ 101 (9.8) 42/392 (10.7) 57 (9.10) 59/639 (9.2) 41/394 (10.4) Basosquamous 11 (1.1) 6/392 (1.5) 5 (0.8) 8/639 (1.3) 3/394 (0.8) Appointment year** 2011 172/1020 (16.9) 67/385 (17.4) 102/616 (16.6) 107/629 (17) 64/389 (16.5) 2012 240/1020 (23.5) .00 87/385 (22.6) 149/616 (24.2) .54 138/629 (21.9) 102/389 (26.2) .42 2013 332/1020 (32.5) 135/385 (35.1) 193/616 (31.3) 213/629 (33.9) 118/389 (30.3) 2014 276/1020 (27.1) 96/385 (24.9) 172/616 (27.9) 171/629 (27.2) 105/389 (27.0) Operative scar size, cmyyzz #0.50 268/1032 (26) 93 (23.7) 170/621 (27.4) 119/638 (18.7) 148/392 (37.8) 0.6-1.0 478/1032 (46.3) .00 191 (48.7) 277/621 (44.6) .54 320/638 (50.2) 158/392 (40.3) .00 1.1-2.0 179/1032 (17.3) 67 (17.1) 109/621 (17.6) 134/638 (21.0) 45/392 (11.5) [2.0 107/1032 (10.4) 41 (10.5) 65/621 (10.5) 65/638 (10.2) 41/392 (10.5)

A 38-Year-Old Man With Extensor Surface Papules

A 38-year-old morbidly obese man presents with a 1-month history of rash on the extensor surfaces of his hands, forearms, elbows, shoulders, flanks, and upper thighs. The rash is nonpruritic but is associated with burning pain. The patient has had no fevers, shortness of breath, recent viral syndromes, or recent travel. He has a history of pancreatitis several years prior, recent repair of a tibial fracture, ankle osteoarthritis, cholelithiasis, seizure disorder, and bipolar disorder. He has a family history of type 2 diabetes in his father and brother. His current medications include phenobarbital, levetiracetam, quetiapine, lorazepam, fluoxetine, tramadol, aspirin, celecoxib, and gabapentin, none of which were started in the past few months. Skin examination reveals hundreds of bright pink papules with central yellow hue distributed symmetrically over his dorsal hands, elbows, shoulders, and thighs (Figure 1). The remainder of the examination is unremarkable.

Genitocrural agminated papules.

Departments of Dermatology and Pathology, er Medical Center, Danville. urces: None. f interest: The authors, editors, and peer reviewers have ant financial relationships. quests: Nektarios I. Lountzis, MD, Department of ology, Geisinger Medical Center, 115 Woodbine Ln, de 52-06, Danville, PA 17822. E-mail: nilountzis@ r.edu. Dermatol 2010;62:e1. /

Enlarging scalp nodule in an elderly woman

36.00 the American Academy of Dermatology, Inc. /j.jaad.2009.06.079