Kachiu C. Lee

Complications Associated With Use of Levamisole-Contaminated Cocaine: An Emerging Public Health Challenge

Levamisole is an immunomodulatory agent that was used to treat various cancers before being withdrawn from the United States market in 2000 because of adverse effects. Levamisole is currently approved as an antihelminthic agent in veterinary medicine, but is also being used illicitly as a cocaine adulterant. Potential complications associated with use of levamisole-laced cocaine include neutropenia, agranulocytosis, arthralgias, retiform purpura, and skin necrosis. Treatment is primarily supportive, and skin lesions typically resolve with cessation of cocaine use. The incidence of hospitalizations related to use of levamisole-contaminated cocaine continues to increase and clinicians should be aware of the more common clinical manifestations.

Melanoma in situ : Part I. Epidemiology, screening, and clinical features

The incidence of melanoma has steadily increased over the past 3 decades, with melanoma in situ comprising a disproportionately high percentage of the rising incidence. Our understanding of melanoma in situ has been shaped by epidemiologic and clinical studies. Central to a review of melanoma in situ is a focus on its epidemiology, pathology, biologic behavior, treatment, and clinical outcome, which may differ significantly from that of malignant melanoma. Part I of this continuing medical education article reviews the epidemiology, risk factors, and clinical features of melanoma in situ; part II covers the histopathology, treatment options, and clinical management.

Prospective Quality of Life Impact of Actinic Keratoses: Observations from the Veterans Affairs Topical Tretinoin Chemoprevention Trial

Actinic keratoses (AKs) are common dysplastic lesions with potential to transform into keratinocyte carcinomas (KC; basal and squamous cell carcinomas) (1), and they present a substantial cost because they are so common (2). A recent cross-sectional analysis found that higher AK counts and past use of topical 5-fluorouracil (5-FU) are predictors of worse quality of life (QoL), with 5-FU usage being an indication of a large number of AKs in the past (3). Given these associations, our rationale for this study was to determine whether QoL is associated prospectively with increases in AK counts in a population with history of multiple KCs.

Melanoma in situ: Part II. Histopathology, treatment, and clinical management

Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Similarly, the approach to treatment should take into account the potential for MIS to transform into invasive melanoma, which has a significant impact on morbidity and mortality. Part II of this continuing medical education article reviews the histologic features, treatment, and management of MIS.

Gender differences in tumor and patient characteristics in those undergoing Mohs surgery.

BACKGROUND Nonmelanoma skin cancer is the most common cancer in the United States, and when indicated, Mohs micrographic surgery (MMS) is an effective method for tumor removal. Few studies have focused on gender-specific characteristics among those undergoing MMS. OBJECTIVE To elucidate patient- and tumor-specific characteristics in female MMS patients. MATERIALS AND METHODS We performed a retrospective chart review of 12,344 consecutive patients undergoing MMS from 2005 to 2012. RESULTS There was a 1.5:1 male predominance in the presentation of basal cell carcinoma (BCC) for MMS. However, BCC comprised 72% of tumors in women compared with 63% in men. Presenting tumor sizes of BCCs were smaller in women (0.9 vs 1.2 cm2, p < .01). Superficial BCCs were more common in women (p < .001). Women had fewer squamous cell carcinoma (p < .01) and squamous cell carcinoma in situ (p < .01). They were more likely to present with tumors on their legs and central facial areas, whereas men had more tumors on their scalps and ears. Plastic surgery referral was over twice as common in the female population (p < .01). CONCLUSION In our data set, significant gender-specific differences were found in women compared with men undergoing MMS. These findings may be the result of discrepancies in sun exposure, protective behavior, and cosmetic concern.

What Is the Evidence for Effective Treatments of Acquired Epidermodysplasia Verruciformis in HIV-Infected Patients?

Clinical Question: What is the evidence for effective treatments for acquired epidermodysplasia verruciformis in human immunodeficiency virus (HIV) infected patients?

Cutaneous manifestations of angioimmunoblastic T-cell lymphoma

To the Editor: A 69-year-old previously healthy woman presented with a 5-day history of cough, low-grade fever, and rash. On examination, she had multiple, ill-defined, scattered pink-red, 0.3to 1-cm papules on the upper chest (Fig 1) and generalized lymphadenopathy. Laboratory values were normal except for hemoglobin 8.2 g/dL, platelets 146 3 10/L, and white blood cell count 9.3 3 10/L, with 2% bands. A skin biopsy specimen showed a superficial and deep perivascular and intralymphatic infiltrate of atypical lymphocytes, with scattered mitoses and admixed plasma cells (Fig 2). The infiltrate was composed of CD3 (70%), CD4 (70%), and CD5 (70%) T cells, with admixed CD8 (20%) T cells and CD20 (30%-40%) B cells. Polymerase chain reaction (PCR) testing was positive for Epstein-Barr virus (EBV). There were no and T-cell receptor (TCR) gene rearrangements. An excisional biopsy specimen of the supraclavicular lymph node showed paracortical expansion with a lymphoid infiltrate of small-to-medium cells and proliferation of high endothelial venules. Lymphoid cells had irregular nuclei, and clustered around lymphoid follicules and high endothelial venules. Large mononuclear cells were seen in the paracortex. The atypical cells were positive for CD3, CD4, CD10 ( partial), and EBV DNA by PCR. The histologic and immunophenotypic features were consistent with angioimmunoblastic T-cell lymphoma (AITL) with TCRand gene rearrangements. A bone-marrow biopsy specimen demonstratedmarrow involvement. Cytogenetic studies revealednormal findings. Shewas treated with cyclophosphamide, Adriamycin, vincristine, and prednisone, which improved her constitutional symptoms and papular eruption. AITL comprises 18% of all T-cell lymphomas. It presents acutely at a mean age of 65 years. Approximately 50% of the cases have a morbilliform eruption on the trunk. Given the prevalence of this skin manifestation in patients with AITL, it is postulated that the morbilliform eruption is a specific manifestation of the lymphoma. In addition, PCR testing of the skin is frequently positive for EBV and TCR gene rearrangements. It is associated with generalized lymphadenopathy (91%), constitutional symptoms (77%), cough/dyspnea (27%), and thrombocytopenia (20%). Other cutaneous presentations

Tumor recurrence after Mohs micrographic surgery

To the Editor: An otherwise superb account of the cutaneous manifestations of Crohn’s disease is unfortunately incomplete because Thrash et al have omitted genital presentations, particularly penile edema/lymphedema/granulomatous lymphangitis. Genital involvement is rare in Crohn’s disease but can be encountered as genital (‘‘knife-cut’’) ulcers, fistulae, fissures, abscesses, and genital edema. In 20 years of specialized male genital clinical activity, I (C.B.B.) have diagnosed and managed the last situation about a dozen times. In some patients (over a third in my experience) it can be the first and only intimation of Crohn’s disease, thus is an important pointer to gastrointestinal investigations and the confirmation or exclusion of Crohn’s disease.

Krokodil: From Russia With Love

51. Cavet J, Dickinson AM, Norden J, Taylor PR, Jackson GH, Middleton PG. Interferon-gamma and interleukin-6 gene polymorphisms associate with graft-versus-host disease in HLA-matched sibling bone marrow transplantation. Blood. 2001;98(5): 1594-1600. 52. Singh A, Sharma P, Kar HK, et al; Indian Genome Variation Consortium. HLA alleles and amino-acid signatures of the peptide-binding pockets of HLA molecules in vitiligo. J Invest Dermatol. 2012;132(1):124-134.

Safety of Cosmetic Dermatologic Procedures During Pregnancy

BACKGROUND Safety of cosmetic procedures in pregnant women has not been extensively studied. Maternal and fetal health risks are important to consider in any procedure performed. With the increasing popularity of cosmetic procedures, dermatologic surgeons will be faced with scenarios necessitating knowledge regarding the safety of such procedures during pregnancy. Furthermore, dermatologic surgeons may inadvertently perform cosmetic procedures during the first trimester, before the patient is aware of the pregnancy. OBJECTIVE To investigate the safety of cosmetic procedures during pregnancy and the postpartum period. METHODS AND MATERIALS A literature search of PubMed and Google Scholar was conducted of all English‐language articles published from 1960 through 2012. RESULTS Definitive recommendations on the safety of procedures such as chemical peels, injectables, fillers, and most laser therapies during pregnancy cannot be made. The safety of onabotulinum toxin usage is well documented in the neurology literature, although isolated events of miscarriage have been reported with high doses of toxin in women with a previous history of miscarriage. Carbon dioxide laser therapy for genital condylomas has considerable evidence supporting its safety during pregnancy. CONCLUSION There is a lack of controlled trials addressing the safety of cosmetic procedures during pregnancy and postpartum periods. It is advisable to delay elective cosmetic procedures until after the baby is born.