Jordan B. Slutsky

Large congenital melanocytic nevi: associated risks and management considerations.

Large congenital melanocytic nevi (LCMN) in neonates can cause considerable concern for parents, family members, and physicians. A detailed understanding of the medical risks, including cutaneous melanoma (CM), extracutaneous melanoma (ECM), and neurocutaneous melanocytosis (NCM), as well as the psychological stress that these lesions can cause in patients, will guide informed management decisions as well as provide comfort to parents. Current data indicate that LCMN greater than 20 cm, and more likely greater than 40 to 60 cm, are the lesions at greatest risk for complications such as CM, ECM, and NCM. Additionally, lesions on the trunk are at greater risk for developing CM, and LCMN in association with numerous satellite nevi are at greatest risk for NCM. Individualized management plans, including clinical observation, magnetic resonance imaging (MRI), and possibly surgery should be based on the risk versus benefit ratio, taking into account the size of the LCMN, its location, the number of satellite nevi, symptoms, and numerous other factors which will be reviewed. This paper will provide a detailed analysis of the risks associated with LCMN, as well as a discussion regarding management and treatment options.

Reflectance confocal microscopic features of dermatophytes, scabies, and Demodex

R EFLECTANCE CONFOCAL MICROSCOPY PROvides in vivo imaging of the epidermis and superficial dermis at cellular level resolution and can be used to detect cutaneous fungal and parasitic infestations. Reflectance confocal microscopy of an erythematous annular scaly patch on the abdomen reveals branching fungal hyphae (Figure 1, arrows), diagnostic of tinea corporis. A linear burrow on the wrist of a pruritic patient demonstrates Sarcoptes scabiei eggs with developing mites (Figure 2, wide arrow) and feces (Figure 2, narrow arrows). Characteristic features of Demodex folliculorum, which can be seen moving in a video that is available online (http://www.archdermatol.com), are also shown in Figure 3: 8 legs (4 of which are indicated by narrow arrows) and an elongated body (wide arrow). Figure 4 reveals the native state of Demodex, with tails (arrows) protruding from a hair follicle (F). In vivo visualization of cutaneous organisms with reflectance confocal microscopy at the bedside provides an alternative to scrapings, microscopy, cultures, and biopsies.

Evaluation of the definitions of "high-risk" cutaneous squamous cell carcinoma using the american joint committee on cancer staging criteria and national comprehensive cancer network guidelines.

Recent guidelines from the American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) have been proposed for the assessment of “high-risk” cutaneous squamous cell carcinomas (cSCCs). Though different in perspective, both guidelines share the common goals of trying to identify “high-risk” cSCCs and improving patient outcomes. Thus, in theory, both definitions should identify a similar proportion of “high-risk” tumors. We sought to evaluate the AJCC and NCCN definitions of “high-risk” cSCCs and to assess their concordance. Methods. A retrospective review of head and neck cSCCs seen by an academic dermatology department from July 2010 to November 2011 was performed. Results. By AJCC criteria, most tumors (n = 211,82.1%) were of Stage 1; 46 tumors (13.9%) were of Stage 2. Almost all were of Stage 2 due to size alone (≥2 cm); one tumor was “upstaged” due to “high-risk features.” Using the NCCN taxonomy, 231 (87%) of tumors were “high-risk.” Discussion. This analysis demonstrates discordance between AJCC and NCCN definitions of “high-risk” cSCC. Few cSCCs are of Stage 2 by AJCC criteria, while most are “high-risk” by the NCCN guidelines. While the current guidelines represent significant progress, further studies are needed to generate a unified definition of “high-risk” cSCC to optimize management.

The Zig-Zag Pattern of Lentigo Maligna

D E R M O S C O P I C C L U E S T O L E N T I G O maligna (LM) include asymmetrical pigmented follicular openings, perifollicular slate-gray dots and granules, circles within circles, atypical blood vessels, and linear pigmented lines forming rhomboidal structures. We have observed a previously unreported dermoscopic pattern in LM that consists of brown to bluish gray dots and lines arranged in an angulated linear pattern, creating a zig-zag appearance (Figures 1, 2, 3, and 4). The zig-zag pattern probably represents incompletely formed rhomboidal structures. Like other dermoscopic findings, the zigzag pattern is not pathognomonic for LM, but in our experience, it is a suggestive dermoscopic pattern that may aid in the diagnosis of some otherwise difficult to diagnose LMs. All of the dermoscopic structures seen in LM can also be manifested in pigmented actinic keratoses, including the zig-zag pattern. However, one clinical clue to differentiate pigmented actinic keratoses from LMs is the presence of a rough texture in the former.

Alkaline Ceramidase 1 Protects Mice from Premature Hair Loss by Maintaining the Homeostasis of Hair Follicle Stem Cells

Summary Ceramides and their metabolites are important for the homeostasis of the epidermis, but much remains unknown about the roles of specific pathways of ceramide metabolism in skin biology. With a mouse model deficient in the alkaline ceramidase (Acer1) gene, we demonstrate that ACER1 plays a key role in the homeostasis of the epidermis and its appendages by controlling the metabolism of ceramides. Loss of Acer1 elevated the levels of various ceramides and sphingoid bases in the skin and caused progressive hair loss in mice. Mechanistic studies revealed that loss of Acer1 widened follicular infundibulum and caused progressive loss of hair follicle stem cells (HFSCs) due to reduced survival and stemness. These results suggest that ACER1 plays a key role in maintaining the homeostasis of HFSCs, and thereby the hair follicle structure and function, by regulating the metabolism of ceramides in the epidermis.

Lichenoid reaction as a potential immune response marker of intratreatment histological response during successful vismodegib treatment for a giant basal cell carcinoma.

We report an 83 year‐old patient with a 13 × 7.5 cm2 basal cell carcinoma (BCC) successfully treated with the combination of vismodegib and minimal surgery. On Day 109, a 0.9 cm papule suspicious for residual BCC was seen centrally within a large pink atrophic plaque. This lesion was excised; pathology confirmed BCC with negative surgical margins. Simultaneously, suspecting noncontiguous histologic response, we performed 21 biopsies at the periphery of the pretreatment tumor location. Seventeen (17/21, 81%) revealed lichenoid dermatitis. No tumor was seen on any. We believe the lichenoid dermatitis observed is a novel finding for two reasons. First, it may be considered a marker of a positive intratreatment response. This may help guide clinicians on the optimal treatment duration of vismodegib to maximize efficacy and mitigate side effects. Second, we think it suggests an additional mechanism of vismodegib action, possibly via local immune effects. Further investigations are warranted.

Bovine Collagen Xenograft Repair of Extensive Surgical Scalp Wounds With Exposed Calvarium in the Elderly: Increased Rates of Wound Healing.

BACKGROUND Postsurgical scalp wounds that extend to the calvarium present a challenge for repair, especially in the elderly patient with multiple comorbidites. When second-intention healing is selected for closure, patients often have prolonged healing times. OBJECTIVE To assess the clinical outcomes of animal-derived collagen xenograft placement on postsurgical scalp wounds extending to the calvarium. METHODS Eleven patients (ages, 61 through 95 years) with calvarium-exposed wounds treated solely with bovine-derived collagen xenografts were reviewed with follow-up extending 12 to 30 weeks after initial surgery. RESULTS Increased rates of healing were found in the xenograft-treated wounds as compared with previous studies of calvarium-exposed wounds healed by second intention alone. Advantages of animal-derived collagen xenografts include immediate coverage of the wound, simple application, low cost, and avoidance of the morbidity associated with local flap, graft, and free flap repairs. CONCLUSION In patients with postsurgical scalp defects with exposed calvarium, collagen xenograft placement may expedite second-intention healing and offer other advantages in the elderly population.

Modified Slow Mohs Technique for Treatment of Cellular Neurothekeoma of the Lip in a Pediatric Patient

Cellular neurothekeoma is a rare, benign soft tissue neoplasm with a risk of local recurrence. It presents a challenge to diagnose because of its histologic similarities to other dermal tumors including plexiform fibrohistiocytic tumor. This distinction is important because each of these tumors has a different behavior pattern and risk of recurrence and distant metastasis. In addition, it can be difficult to obtain clear surgical margins especially in the setting of incomplete resection or recurrence because of its similarity to scar tissue on routine pathologic staining, often necessitating specialized staining techniques (Table 1). To reduce recurrence, it is important to obtain accurate tumor resection margins, especially before proceeding with definitive facial reconstruction as methods of tissue rearrangement will distort the original tumor bed. We present a case of cellular neurothekeoma of the lip in a pediatric patient with the challenges of diagnostic accuracy, tumor clearance, and reconstruction which was successfully treated by a multidisciplinary approach using a novel “modified” slow Mohs technique.

Deep Venous Thrombosis and Pulmonary Embolism Following Outpatient Dermatologic Surgery.

A 61-year-old Caucasian man with a history of coronary artery disease status after cardiac stents, asthma, and hyperlipidemia was referred to our clinic by his dermatologist for a biopsy-confirmed melanoma on the medial aspect of his right knee, with a Breslow depth of 0.51 mm, transected at the base. The patient’s medications included daily Clopidogrel, Fluticasone/Salmeterol, Atorvastatin, and Metoprolol. We planned a staged excision surgery given the transection to determine whether there was any remaining melanoma that could upstage the disease and whether subsequent sentinel lymph node biopsy would be considered. We did not recommend nor did he discontinue any medications before surgery.

Acral Petechiae and Purpuric Plaques in a 3-Year-Old Girl—Quiz Case

An 82-year-old woman presented with a 3-month history of an asymptomatic growth on the left posterior shoulder. She denied trauma, tenderness, bleeding, or pruritus associated with the lesion. The patient had a history of a nodular basal cell carcinoma on the nasal tip and had undergone cutaneous micrographic surgery in 2001 and excision of a keratoacanthoma on the left wrist in 2004. The physical examination revealed an 8 6-mm smooth, skin-colored, dome-shaped papule on the left posterior shoulder (Figure 1). A shave biopsy was performed (Figure 2 and Figure 3). What is your diagnosis?