Fleta N. Bray

Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy

Ionizing radiation is an important treatment modality for a variety of malignant conditions. However, development of radiation-induced skin changes is a significant adverse effect of radiation therapy (RT). Cutaneous repercussions of RT vary considerably in severity, course, and prognosis. When they do occur, cutaneous changes to RT are commonly graded as acute, consequential-late, or chronic. Acute reactions can have severe sequelae that impact quality of life as well as cancer treatment. Thus, dermatologists should be informed about these adverse reactions, know how to assess their severity and be able to determine course of management. The majority of measures currently available to prevent these acute reactions are proper skin hygiene and topical steroids, which limit the severity and decrease symptoms. Once acute cutaneous reactions develop, they are treated according to their severity. Treatments are similar to those used in prevention, but incorporate wound care management that maintains a moist environment to hasten recovery. Chronic changes are a unique subset of adverse reactions to RT that may develop months to years following treatment. Chronic radiation dermatitis is often permanent, progressive, and potentially irreversible with substantial impact on quality of life. Here, we also review the etiology, clinical manifestations, pathogenesis, prevention, and management of late-stage cutaneous reactions to radiotherapy, including chronic radiation dermatitis and radiation-induced fibrosis.

Exogenous Ochronosis: A Comprehensive Review of the Diagnosis, Epidemiology, Causes, and Treatments

Exogenous ochronosis (EO) can be an unintended psychologically troubling condition for patients who are already being treated for longer-term hyperpigmentation disorders such as melasma. Early diagnosis is key in order that the offending agent can be stopped to prevent further disfiguring discoloration. EO can be diagnosed in the right clinical setting with the aid of dermatoscopy, which can assist in early diagnosis and may negate the need for a biopsy. Laser modalities using Q-switched lasers of longer wavelengths and combination laser dermabrasion treatments have shown the most significant results with minimal adverse events. However, further large-scale studies are needed to determine optimal treatment modalities. Although considered uncommon, the incidence of EO will likely continue to increase with the growth of immigrant populations and the use of skin-lightening agents above the FDA’s recommended over-the-counter concentrations, without the guidance of a dermatologist.

Management of familial benign chronic pemphigus

Benign familial chronic pemphigus or Hailey–Hailey disease is caused by an autosomal dominant mutation in the ATP2C1 gene leading to suprabasilar acantholysis. The disease most commonly affects intertriginous areas symmetrically. The chronic nature of the disease and multiple recurrences make the disease bothersome for patients and a treatment challenge for physicians. Treatments include topical and/or systemic agents and surgery including laser. This review summarizes the available treatment options.

Lasers and nevus of Ota: a comprehensive review

Nevus of Ota is a benign dermal melanocytic nevus that typically affects Asian children and women. The nevus presents as unilateral blue-gray hyperpigmented macules and patches scattered along the first and second divisions of the trigeminal nerve. Individuals with nevus of Ota experience emotional and psychosocial distress related to cosmetic disfigurement and often look for treatment options. Unfortunately, even when treated early, lesions of nevus of Ota are still difficult to treat. The use of lasers for the treatment of nevus of Ota lesions has become helpful in the management of dermal nevi. Currently, Q-switched (QS) lasers have been the most studied and demonstrated positive results for treatment of nevus of Ota. The purpose of this review article is to summarize the clinical efficacy and side effects associated with QS lasers and the treatment of nevus of Ota lesions.

Light and laser therapies for the treatment of sebaceous gland hyperplasia a review of the literature

Sebaceous gland hyperplasia (SGH) is a benign cutaneous condition that presents primarily on the face and increases with UVB exposure and ageing. These lesions are a common cosmetic concern but are difficult to treat, as the entire sebaceous gland needs to be destroyed to prevent recurrence. Traditional methods of treatment include: cryosurgery, electrodessication, curettage, shave excision and topical trichloroacetic acid. These methods have an increased risk of skin discoloration and scarring to the area of treatment that may lead to inferior cosmetic outcomes. Alternatively, oral isotretinoin can treat SGH, but is a known teratogen in pregnancy and has high relapse rates with discontinuation. A systematic review of the literature was performed to look at photodynamic therapy (PDT) and laser treatment for SGH. According to the results of this study, PDT, lasers and combinations of the two treatments were found to offer alternatives to the more conventional techniques with better outcomes. In particular, the use of wavelength‐specific laser for the sebaceous gland of 1720 nm were found to have better outcomes and provide minimal damage to surrounding tissues. Additionally, combination PDT with aminolevulinic acid and pre‐treatment with carbon dioxide laser ablation or pulse‐dyed laser offered higher cure rates over stand‐alone laser or PDT treatments in a shorter number of sessions with similar transient side‐effects. However, further large‐scale prospective studies with adequate follow‐up are required to confirm these findings and those for sebaceous gland‐specific lasers.

1064 nm Q-switched Nd:YAG laser for the treatment of Argyria: a systematic review

Argyria is a benign skin disease characterized by blue to slate‐grey discoloration that is caused by deposition of silver granules in the skin and/or mucus membranes as a result of long‐term ingestion of ionized silver solutions or exposure to airborne silver particles. The skin discoloration can be generalized or localized and is exacerbated by sunlight. The skin discoloration is usually permanent, and until recently, there has been no effective treatment for argyria. Over the past 6 years, a number of case reports and one case series have described cases of argyria that were successfully treated with a 1064 nm Q‐switched (QS) neodymium‐doped yttrium aluminium garnet (Nd:YAG) laser; however, a review of these studies has never been reported in the dermatologic literature. To review the use of the 1064 nm QS Nd:YAG laser for the treatment of argyria. A search of the National Library of Medicines PubMed Database and the SCOPUS Database was performed to find articles that detailed the treatment of argyria with 1064 nm QS Nd:YAG laser. Six articles were selected for inclusion in this review. Each article was reviewed and summarized in a table. A 1064 nm QS Nd:YAG laser offers a novel and effective treatment for argyria. A systematic review of the dermatologic literature revealed a limited number of case reports and case series using this treatment. However, the results gleaned by the authors from the literature review provide important information to the clinician. For patients with argyria, a single pass of the 1064 nm QS Nd:YAG laser offers immediate, effective and sustained pigment clearing without any long‐term adverse effects.

Cells to Surgery Quiz: August 2015.

QUESTIONS 1. A 50-year-old man underwent Mohs micrographic surgery for removal of a basal cell carcinoma on the nasal dorsum/sidewall. The resulting full-thickness wound pictured above elicits which of the following? a. Innate immune response. b. Adaptive immune response. c. Antigen presentation by dendritic cells. d. All of the above. e. None of the above. Cells to Surgery Quiz: August 2015 Mohammad-Ali Yazdani Abyaneh1, Brian J. Simmons1, Fleta N. Bray1, Mohammed Alsaidan1 and Keyvan Nouri1 Journal of Investigative Dermatology (2015) 135, e16. doi:10.1038/jid.2015.215

The use of radiofrequency in combination with lasers for acne scars

populations We write with reference to the article published online (May 6, 2015) by Balta et al., investigating psychiatric symptoms, sleep quality, and coping strategies in patients with psoriasis. The authors should be commended for this interesting work in a poorly understood and researched area of psoriasis. However, we note the following points. First, we know that psoriasis is a condition associated with significant morbidity, with estimates indicating up to 58% of patients experience depression, about 50% experience obstructive sleep apnea, 10% have inflammatory bowel disease or Crohn’s disease, and up to 40% experience psoriatic arthropathy. There are clearly strong links between sleep disturbance and mental and physical health; however, the authors chose to exclude patients with common comorbidities, severely limiting the generalizability of their results to the wider psoriasis population. Undoubtedly, the use of a fairly clean sample may have contributed to the lack of significant results across some sleep domains. Second, although the Pittsburgh Sleep Quality Index (PSQI) is a robust measure of sleep quality, the authors fail to report the full data for all seven domains (the sleep disturbance component is not included despite being cited in the Methods section) or global PSQI score. Without these data, particularly the total PSQI score, we are given a limited picture of sleep in this population. It would aid understanding if the authors provided all of the descriptive data relating to PSQI scores, particularly the proportion of subjects scoring above and below the cut-off score of 5. Lack of reporting of these data is a commonly observed problem in sleep research with medical populations. The significant and strong correlation between PASI score and sleep efficiency is particularly interesting and requires further scrutiny in future research to unpick underlying mechanisms and causal direction. Building on the work of Balta et al., we suggest that prospectively designed studies are required, employing state-of-the-art sleep measurements, to advance understanding of the nature of sleep disturbance in psoriasis and associated linkage with important health and disease outcomes.

US dermatologists' knowledge of current sunscreen recommendations

course, whereas NBD is progressive and leaves neurological sequelae. Accompanying symptoms including skin lesions, thrombophlebitis, uveitis, and positivity for HLAB51 are useful for the diagnosis of NBD. Diagnosing NSD is difficult without rash, as the diagnosis hinges on skin lesions. However, the rash does not necessarily coincide with neurologic symptoms. In such possible NSD cases, careful follow-up for the development of skin lesions is important. As high associations with HLA-B54 and Cw1 have been reported in SS, HLA typing is also useful. The awareness of central nervous system involvement of the SS is important to lead to the best therapeutic solution.

Jonathan Hutchinson--The Eponyms Physician.

Jonathan Hutchinson was born in Selby, England, in 1828. He is well known for the eponymous terms named after him and his catchy descriptive terms thatwere accurate andwell-remembered, for instance, the “apple jelly” for lupus vulgaris, the “screwdriver” for central incisor peg teeth, and the “ground glass” for cornea of congenital syphilis. He believed that illustrations were a necessary adjunct of clinical observations.He employed an artist to visit thewards andpaint pictures of skin lesions, and later he built amuseum for his collection of drawings, illustrations,andwaxmodels forpathologicalanddermatologicalconditions. Hutchinson was a surgeon, dermatologist, ophthalmologist, and pathologist. Of note, his interest in pathology was influenced by James Paget. His research on syphilis started after observing severe disease of the skull bones in a young man whose mother had had syphilis. After extensive research, his first book Syphilitic Diseases of Ears and Eye was published in 1863. He named syphilis “the great imitator” and described the triad of hereditary syphilis, which was later named “Hutchinson’s Triad.” The list of the eponymous terms named after Hutchinson is long. It includes Hutchinson sign, Hutchinson teeth, Hutchinson freckle, Hutchinson disease, Hutchinson mask, Hutchinson patch, Hutchinson angina, Hutchinson facies, Hutchinson pupil, Hutchinson summer prurigo, Hutchinson syndrome, HutchinsonWeber-Peutz syndrome, and Hutchinson-Gilford progeria. Hutchinson medical bibliography has almost 1200 items. He wrote every single word in the 11 volumes of Archives of Surgery, published between 1889 and 1900. He also published 4 volumes of Lectures in Clinical Surgery; the first volume had 20 chapters on dermatology. Hutchinsonhadpeculiar ideas.Hebelieved that leprosywas caused byeatingbadlycured fish.HetraveledtoNorway,Egypt, theMiddleEast, and India togathermaterials in supportofhishypothesis.AlthoughHansen had discovered the leprosy bacillus in 1874, Hutchinson published his last book On Leprosy and Fish Eating in 1906 justifying his beliefs. He also believed that alopecia areatawas amodified ringworm, or a sequela of ringworm, even though all his microscopic examinations were negative for fungal infection. Although hewas opposedwomen to entering themedical profession, he lovedhiswifewithdeepaffection and wrote letters to her almost daily in periods of separation. He saw the person who had the disease first; thus, he would label new disease conditions with the patient’s name. Examples are Mabey malady, Penmann disease, Mortimer malady, and Branford legs. Hutchinson died in Haslemere, Surrey, England in 1913. On his tombstone was inscribed “A Man of Hope and Forward Looking Mind.” Hutchinson’scontributions tomedicineandthefieldofdermatologycontinue tomake an important impact on the recognition and diagnosis of disease.