James A. Yiannias

Erythema elevatum diutinum: a clinical and histopathologic study of 13 patients.

BACKGROUND Erythema elevatum diutinum is a rare condition representing a chronic leukocytoclastic vasculitis. OBJECTIVE Clinical and laboratory features of the disease were reviewed to better understand the disease. METHODS The medical records and histopathologic slides of 13 patients with erythema elevatum diutinum were studied. RESULTS The lesions were violaceous, deep red, or brown and typically were papules or plaques. Lesions were most often located on the extensor surfaces of the extremities. Associated medical problems included hematologic abnormalities in six patients: IgA clonal gammopathies (four), multiple myeloma (one), and myelodysplasia (one). Erythema elevatum diutinum preceded the myeloproliferative disorders by an average of 7.8 years. All patients showed vasculitis. Leukocytoclasia was present in 27 of 35 specimens. The predominant cell type in the inflammatory infiltrate was polymorphonuclear leukocytes or a mixture of polymorphonuclear leukocytes and lymphocytes. CONCLUSION The most significant finding of this study is the association of erythema elevatum diutinum with hematologic disease, most frequently an IgA monoclonal gammopathy.

Scurvy : a disease almost forgotten

Background  Although much decreased in prevalence, scurvy still exists in industrialized societies. Few recent large studies have examined its pathogenesis, signs, and symptoms.

Relevant contact sensitivities in patients with the diagnosis of oral lichen planus

BACKGROUND The concept of contact allergy aggravating or inducing oral lichenoid mucositis diagnosed as oral lichen planus (OLP) is well recognized but somewhat controversial. OBJECTIVE We sought to identify clinically relevant contact allergens that may be important in the management of patients with OLP. METHODS We retrospectively reviewed patients with OLP who had patch tests performed at Mayo Clinic Rochester and Mayo Clinic Scottsdale from 1994 to 1997 and 1988 to 1997, respectively. RESULTS Patch tests were performed on 46 patients with a clinical and histopathologic diagnosis of OLP. Of these, 25 (54%) had positive patch test results. Eighteen (72%) of the patients with positive results had clinically relevant reactions. Of the patients with positive metal reactions, 5 had improvement after removal of the metal prosthesis or restoration. Six others noted that their most troublesome areas were adjacent to metal dental restorations. Six patients with reactions to flavorings and one patient with an acrylate dental retainer sensitivity had improvement after avoiding these allergens. CONCLUSION Our findings support the concept that contact allergy to metals, flavorings, and plastics can be important in the pathogenesis and management of patients with oral lichenoid mucositis diagnosed as OLP.

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.

Allergic contact dermatitis in 136 children patch tested between 2000 and 2006

Background  Allergic contact dermatitis is often under‐recognized in the pediatric population but it may affect greater than 20% of this age group.

Contact dermatitis to cosmetics, fragrances, and botanicals.

ABSTRACT:  Cosmetics, fragrances, and botanicals are important causes of allergic contact dermatitis. Identifying and avoiding the causative allergens can pose a challenge to both the patient and the dermatologist. The site of involvement can give the investigator clues to the cause of the eruption in many cases. Fragrances and preservatives are the two most clinically relevant allergens in cosmetics. Botanicals are being added to cosmetics because of consumer demand and are now being recognized as sources of allergy as well. Patch testing allows for the detection of allergens that are potentially relevant in the genesis of the patients eczema. Common skin‐care product allergens, including fragrances and botanicals as well as those found in sunscreen, nail, and hair‐care products, are reviewed. Practical methods of allergen avoidance are also discussed.

Results of patch testing to personal care product allergens in a standard series and a supplemental cosmetic series: An analysis of 945 patients from the Mayo Clinic Contact Dermatitis Group, 2000-2007

BACKGROUND Patch testing to a standard screening series of allergens in combination with supplemental cosmetic allergens is often used to diagnose allergic contact dermatitis due to personal care products. OBJECTIVE To report results of patch testing to skin care product allergens contained in a standard series and a supplemental cosmetic series and to compare efficacy of this combined series in detecting positive reactions to personal care product allergens with the efficacy of various standard screening series. METHODS Positive reaction rates to skin care product allergens were tabulated for patients who underwent patch testing to both standard and cosmetic series allergens at Mayo Clinic between 2000 and 2007. Data were compared with skin care allergens detected on standard screening series, including the thin-layer rapid use epicutaneous (TRUE) test. RESULTS Of 945 patch-tested patients, 68.4% had at least one positive reaction and 47.3% had at least two positive reactions. Also, 49.4% of patients reacted to at least one preservative; 31.2% reacted to at least one fragrance/botanical additive. Compared with use of our standard series and cosmetic series, use of the TRUE test would have missed 22.5% of patients with preservative allergy, 11.3% with fragrance/botanical allergy, and 17.3% with vehicle allergy. LIMITATIONS Various allergens tested over time, patch test reading by residents, and lack of confirmation of allergen in personal care products. CONCLUSION Standard patch-test screening series miss a substantial number of patients with skin care product ingredient allergy.

Patch testing with a large series of metal allergens: findings from more than 1,000 patients in one decade at Mayo Clinic.

Background: The standard allergen series used in patch testing contains metals that most commonly cause allergic contact dermatitis, but testing with additional metal allergens is warranted for select patients. Objective: To report our experience with patch testing of metals. Methods: We retrospectively analyzed outcomes of 1,112 patients suspected of having metal allergies. Patients were seen from January 1, 2000, through December 31, 2009. Patch testing was performed with 42 metal preparations (6 in the standard series, 36 in the metal series). Results: Patch testing most commonly was performed for patients with oral disease (almost half the patients), hand dermatitis, generalized dermatitis, and dermatitis affecting the lips, legs, arms, trunk, or face. At least one positive reaction was reported for 633 patients (57%). Metals with the highest allergic patch‐test reaction rates were nickel, gold, manganese, palladium, cobalt, Ticonium, mercury, beryllium, chromium, and silver. Metals causing no allergic patch‐test reactions were titanium, Vitallium, and aluminum powder. Metals with extremely low rates of allergic patch‐test reactions included zinc, ferric chloride, and tin. Reaction rates varied depending on metal salt, concentration, and timing of readings. Conclusion: Many metals not in the standard series were associated with allergic patch‐test reactions. The many questions raised by these findings, concerning patch testing with individual metals, will be the subject of future studies.

Oral metal contact allergy: A pilot study on the cause of oral squamous cell carcinoma

Background  Intraoral metal contact allergy may result in mucositis that mimics lichen planus and the pathogenesis of squamous cell carcinoma.

Peripheral T-cell lymphoma presenting as lipoatrophy and nodules

Background  Cutaneous lymphomas have many morphologic forms and clinical features. Lymphoma presents rarely with a constellation of nodules, panniculitis, and localized lipoatrophy. The histopathologic similarities of lymphoma and connective tissue disease panniculitis may create a diagnostic challenge.