Leslie Castelo-Soccio

Treatment of pediatric pyogenic granulomas using β-adrenergic receptor antagonists.

Propranolol and timolol are nonselective ß‐adrenergic antagonists that induce peripheral vasoconstriction and affect angiogenic cytokines. Oral and topical ß‐blocker therapy has become the de facto first‐line treatment for complicated infantile hemangiomas because of its superior efficacy and tolerability. Pyogenic granulomas or lobular capillary hemangiomas are common acquired vascular tumors accounting for 0.5% of all skin nodules in children. Although they are benign vascular proliferations, treatment is often sought because of recurrent episodes of bleeding and for cosmetic considerations. Numerous treatment options are available, but recurrence rates are high. Noninvasive methods of treatment are being sought, particularly for young children. Herein we report a series of seven cases of cutaneous and mucosal pyogenic granulomas treated successfully using oral or topical ß‐blockers.

Massive localized lymphedema: An emerging dermatologic complication of obesity

To the Editor: A 54-year-old morbidly obese male presented with a 3-month history of a red indurated mass on the dependent aspect of his abdomen associated with bullae and peau d’orange appearance (Fig 1). The patient did not report any trauma and had a negative evaluation for underlying endocrine abnormalities, including hypothyroidism. The abdominal lesion was biopsied and showed epidermal thickening, dilated lymphatic channels, dermal edema, and fibrosis (Fig 2). The patient was treated with topical triple paste and binders for abdominal compression with some improvement. Fig 1 Abdominal pannus demonstrating an ill-defined indurated mass with erythema and peau d’orange appearance. Fig 2 Histology of the abdominal mass shows epidermal thickening, dilated lymphatic channels, dermal edema, and fibrosis. (Hematoxylin-eosin stain; original magnifica-tion: ×40.) This case is consistent with massive localized lymphedema (MLL) an emerging dermatologic complication of morbid obesity. MLL, which is a benign overgrowth of soft tissue characterized histologically by chronic lymphedematous changes, has primarily been described in the surgical literature.1–5 The initial case series1 described 14 patients with MLL of the proximal medial thigh. Subsequent case series describe MLL occurring in additional locations, including the abdomen, scrotum, upper extremities, and inguinal regions.2 A review of these case reports suggests that the typical patient with MLL is a morbidly obese (mean weight, 450 lbs) female (females outnumber males by a 2:1 ratio) with a mean age of 48 years old. The mass is frequently located on the thigh, is large (mean size, 32 cm), with a mean weight of 7000 g, and is painless. The mass is pendulous but not very well defined and has overlying chronic lymphedema changes including epidermal thickening and a peau d’orange appearance. There is often local inflammation with erythema and serous drainage. The mass typically has been present for 8 months to 10 years.1,2 Patients appear unbothered by the mass until it interferes with daily activities or the patient develops frequent bouts of cellulitis in this location.2,3,5 Radiologically, there is diffuse edema involving the skin and subcutaneous tissue without extension to muscle. Histologically, there is epidermal thickening, and a dermis marked by dilated lymphatic spaces, dense edema, and extensive dermal fibrosis. The deep tissue shows lobules of mature fat intercepted by pale-staining interlobular septa, with a relative absence of atypical septal fibroblasts and lipoblasts.1,2,5 Although it may clinically mimic lipo-sarcoma and has been called pseudosarcoma as a result, histopathology reveals a benign process with lack of nuclear atypia. Chronic lymphedema may predispose patients to the formation of cutaneous angiosarcomas.3 While the majority of angiosarcomas are seen in the upper extremity of patients who have undergone radical mastectomies, there are two anecdotal cases of angiosarcomas occurring in the lymphedematous tissue of morbidly obese patients.3 Treatment of MLL is difficult. Weight reduction, physical therapy, compression, manual lymphatic drainage, and good skin hygiene are all important to therapy.1,3 Patients are frequently treated with oral and topical antibiotics because of secondary cellulitis. Surgical resection is indicated for the restoration of mobility, to prevent recurrent infections, or if there is any question of malignancy.3,5 In an epidemic of obesity, MLL will likely increase in prevalence; therefore, early identification and treatment may prevent further morbidity for these patients.

Successful Treatment of Acyclovir-Resistant Herpes Simplex Virus With Intralesional Cidofovir

Acyclovir-resistant herpes simplex virus (HSV) has become increasingly common, particularly among patients with human immunodeficiency virus (HIV). We present a case of acyclovir-resistant HSV treated with intralesional cidofovir.

Diagnosis and Management of Alopecia in Children

Alopecia in childhood is a source of high concern, frustration, and anxiety. Delineating types of alopecia and those that are chronic or potentially related to underlying medical problems is important. There are 5 common types of hair loss in children: alopecia related to tinea capitis, alopecia areata spectrum/autoimmune alopecia, traction alopecia, telogen effluvium, and trichotillomania/trichotillosis. Hair-cycle anomalies including loose anagen syndrome can lead to sparse-appearing hair. Rarer reasons for alopecia in children include pressure-induced alopecia, alopecia related to nutritional deficiency or toxic ingestion, and androgenetic alopecia. Congenital lesions should be considered for areas of localized alopecia occurring at birth.

Reliability and Validity of Mobile Teledermatology in Human Immunodeficiency Virus-Positive Patients in Botswana A Pilot Study

IMPORTANCE Mobile teledermatology may increase access to care. OBJECTIVE To determine whether mobile teledermatology in human immunodeficiency virus (HIV)-positive patients in Gaborone, Botswana, was reliable and produced valid assessments compared with face-to-face dermatologic consultations. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study conducted in outpatient clinics and public inpatient settings in Botswana for 76 HIV-positive patients 18 years and older with a skin or mucosal condition that had not been evaluated by a dermatologist. MAIN OUTCOMES AND MEASURES We calculated the κ coefficient for diagnosis, diagnostic category, and management for test-retest and interrater reliability. We also determined sensitivity and specificity for each diagnosis. RESULTS The κ coefficient for test-retest reliability ranged from 0.47 (95% CI, 0.35 to 0.59) to 0.78 (0.67 to 0.88) for the primary diagnosis, 0.29 (0.18 to 0.42) to 0.73 (0.61 to 0.84) for diagnostic category, and 0.17 (-0.01 to 0.36) to 0.54 (0.38 to 0.70) for management. The κ coefficient for interrater reliability ranged from 0.41 (95% CI, 0.31 to 0.52) to 0.51 (0.41 to 0.61) for the primary diagnosis, 0.22 (0.14 to 0.31) to 0.43 (0.34 to 0.53) for diagnostic category, and 0.08 (0.02 to 0.15) to 0.12 (0.01 to 0.23) for management. Sensitivity and specificity for the top 10 diagnoses varied from 0 to 0.88 and 0.84 to 1.00, respectively. CONCLUSIONS AND RELEVANCE Our results suggest that while the use of mobile teledermatology technology in HIV-positive patients in Botswana has significant potential for improving access to care, additional work is needed to improve the reliability and validity of this technology on a larger scale in this population.

Recurrent dermatitis and dermal hypersensitivity following a jellyfish sting: a case report and review of literature.

Jellyfish envenomation often causes an immediate painful vesiculopapular eruption. Less commonly it can cause a type IV allergic hypersensitivity that manifests with delayed or recurrent cutaneous lesions at the primary site or distant from the primary site. These secondary reactivations may be related to high antijellyfish immunoglobulin levels, intracutaneously sequestered antigen, or cross‐reacting venom. Immunomodulators such as pimecrolimus and tacrolimus and topical and intralesional corticosteroid therapy decrease this recurrent dermatitis. We report a case of a 9‐year‐old girl with a recurrent jellyfish dermatitis lasting more than 1 year after the initial envenomation. The dermatitis finally resolved after treatment with tacrolimus and intralesional triamcinolone acetonide therapy.

Disseminated herpes simplex virus (HSV) hepatitis diagnosed by dermatology evaluation.

Herpes simplex virus (HSV) hepatitis is a rare but frequently fulminant disease that presents with anicteric transaminitis, fever, leukopenia, and flu-like symptoms.1 It most frequently affects immunocompromised patients.2 We report a case of a patient with metastatic pheochromocytoma who presented with fever and elevated aminotransferases. HSV hepatitis was diagnosed after skin findings suggested cutaneous HSV.

Sweet Syndrome Associated With New-Onset Systemic Lupus Erythematosus in a 25-Year-Old Man

Sweet syndrome (SS) is a reactive neutrophilic process characterized by tender, erythematous papules and plaques, fever, and leukocytosis and is associated with underlying infections, inflammatory diseases, and malignant neoplasms. To our knowledge, only 2 cases of SS associated with new-onset systemic lupus erythematosus (SLE) have been reported—one in an adult woman and the other in a 14-year-old girl.1,2 We report the first case in an adult man.

PHACE Syndrome: A Retrospective Review of 23 Patients

We present 23 patients with PHACE syndrome showing similarities in our population with data that already exist while highlighting neurodevelopmental occurrences arising in a subset of these patients.

Induced lentiginosis with use of topical calcineurin inhibitors.

tive, technical, and material support: Beach and Wilkinson. Study supervision: Khumalo. Financial Disclosure: None reported. Funding/Support: The original study was supported in part by the North American Hair Research Society (Dr Beach) and the Women’s Dermatologic Society (Dr Beach). Dr Wilkinson is supported by the Medical Research Council (United Kingdom) and performed the laboratory work in facilities partially funded by Wellcome Trust grant 084323 and the Division of Dermatology, University of Cape Town. The cytokines for the current study were funded by a Galderma (South Africa) award for published work 2010 (Dr Khumalo). Role of the Sponsors: The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; or in the preparation, review, or approval of the manuscript. Additional Contributions: We are indebted to Gail Todd, FCDerm,PhD,forenablingparticipantrecruitmentandscalp treatments and to Steven Glassman, MD, who supervised the Ottawa Health Research Institute ethics submission.