Nishit Patel

Advanced treatment modalities for vitiligo.

Background Vitiligo is an acquired multifocal and polygenic dyschromia that affects 1% to 3% of the world and presents as multiple depigmented macules and patches. Traditionally, the treatment of vitiligo has focused on pharmacologic interventions, but nearly half of all treated patients fail to respond successfully. Objective Several advanced techniques exist that can aid dermatologists in treating vitiligo in patients who do not respond favorably to traditional pharmacologic treatments. These advanced interventions include the use of the 308‐nm excimer laser, total body depigmentation therapy with monobenzyl ether of hydroquinone, microdermabrasion, micropigmentation, khellin‐UVA therapy, and surgical management using miniature punch grafting, suction blister grafting, and epidermal cultures. Materials and Methods This article reviews the current literature on these advanced treatment modalities for vitiligo and provides a practical guide for application of these techniques. Results and Conclusion Our ability to treat vitiligo may be imperfect, but through appropriate patient selection and careful application of one or more of these advanced therapies, successful treatment of vitiligo, even in patients refractory to treatment, can be achieved.

Epidermal Anti-Programmed Cell Death-Ligand 1 Expression in TEN Associated with Nivolumab Therapy.

Nivolumab is a programmed cell death receptor‐1 (PD‐1) antibody used in the treatment of metastatic or unresectable melanoma. Cutaneous reactions are the most common adverse events reported with these agents and are rarely severe or life‐threatening. Here we present a case report describing the clinicopathological findings of a patient with a fatal toxic epidermal necrolysis (TEN) eruption associated with use of nivolumab for treatment of metastatic melanoma. The patient developed a pruritic, morbiliform eruption, which slowly progressed over 3 months to a tender, exfoliative dermatosis. Histology initially showed interface dermatitis and subsequently revealed full thickness epidermal necrosis. The diagnosis of TEN was made. From initial biopsy to TEN presentation, there was an increase in the number of CD8+ lymphocytes within the dermal–epidermal junction and an increase of programmed death ligand 1 (PD‐L1) expression in both lymphocytes and keratinocytes. Despite treatment with infliximab, high‐dose steroids and intravenous immunoglobulin, the patient expired. Herein we describe what we believe is the second case of TEN associated with anti‐PD1 therapy reported in the literature. Increased expression of PD‐L1 by immunohistochemistry was observed as the eruption progressed to TEN. Early diagnosis and treatment is necessary in these fatal TEN reactions secondary to the anti‐PD‐1 antibody therapies.

Intralesional 5-fluorouracil (FU) as a treatment for nonmelanoma skin cancer (NMSC): A review

The treatment paradigm for nonmelanoma skin cancer remains surgical. This fact combined with its remarkably high incidence positions it as the fifth most costly cancer to treat in the Medicare population. To address this, consideration of alternative medical therapeutics is warranted. Intralesional 5-fluorouracil is a potentially affordable option that may demand further investigation. This literature review examines current data on its efficacy and adverse effects.

A unique basaloid proliferation encountered during Mohs surgery: potential pitfall for overdiagnosis of basal cell carcinoma.

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Prevalence of cutaneous viral infections in incident cutaneous squamous cell carcinoma detected among chronic lymphocytic leukemia and hematopoietic stem cell transplant patients

Abstract The role of cutaneous viral infections in the development of non-melanoma skin cancer (NMSC), including cutaneous squamous cell carcinoma (SCC), among chronic lymphocytic leukemia (CLL) and blood and marrow transplant (BMT) patients is not established. CLL (n = 977) and BMT (n = 3587) patients treated at the Moffitt Cancer Center were included in a retrospective cohort study. Human papillomavirus (HPV) and human polyomavirus (HPyV) DNA were examined in a subset of incident SCC tumors. Five-year cumulative incidence of NMSC was 1.42% in both BMT (n = 31 NMSCs) and CLL (n = 18 NMSCs) cohorts. Of the nine SCC tumors examined from each cohort, 22.2% and 33.3% were positive for viral DNA in the transplant (HPV 65, MCV) and CLL (HPV 38, HPV 15, HPyV6) cohort, respectively. Enhanced skin cancer screening of BMT/CLL patients should be conducted to better capture incident NMSCs and examine the role of viral infections in these tumors.

Acquired acrodermatitis enteropathica as a presenting sign of celiac disease

Cutaneous manifestations can occur in association with various gastrointestinal diseases.1 When dermatitides present in the setting of unintentional weight loss before a gastrointestinal disease is diagnosed, early recognition can aid in the diagnosis of nutritional deficiency secondary to malabsorption.2 A case of acquired acrodermatitis enteropathica (AE) is reported in the setting of zinc deficiency as a presenting sign of celiac disease (CD).

A comprehensive guide to the surgical management of nonmelanoma skin cancer

The ultimate goal in surgical management of nonmelanoma skin cancer (NMSC) is tumor eradication. Surgical procedures include Mohs micrographic surgery (MMS), surgical excision (SE), curettage and electrodessication (C&E), and cryosurgery. All of these interventions are useful tools in the surgical management of NMSC and each has its unique set of strengths and weaknesses. Tumor clearance rates, postsurgical complications, recurrence rates, cosmesis, and costs can vary greatly based on both the intervention chosen and the characteristics of the lesion being treated. In a large meta-analysis, average recurrence rates for primary squamous cell carcinoma (SCC) were 0.8% for cryotherapy and 1.7% for C&E, representing mostly small or lowrisk lesions. Larger or higher-risk primary SCC is more often treated with other modalities, with recurrence rates reported at 3% for MMS, 5.4% for SE, and 6.4% for radiation therapy. Data on the treatment of basal cell carcinomas (BCCs) are similar with an investigation showing that tumors treated with MMS had the lowest recurrence rates, followed, in order, by those treated with SE, cryosurgery, and C&E.

An overview of the medical management of nonmelanoma skin cancer

Importantly, NMSCs are increasing in prevalence, and full recognition of these diseases as life-threatening entities is paramount. Overall, data supporting adjuvant or systemic therapy in NMSCs are limited, but there are enough reports in the literature to suggest some benefit with systemic agents. Where available, we recommend patients investigate clinical trial options, including phase I studies. Newer targeted therapies and activation of the immune system may provide for a dramatic step forward in the management of these diseases; however, formal clinical trials are necessary to establish these new treatments as a standard of care.

A Survey Analysis on the Management of Moderately Dysplastic Nevi Among Academic Dermatologists Across the United States

REFERENCES 1. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US population, 2012. JAMA Dermatol. 2015;151: 1081-1086. 2. Guy GP Jr, Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med. 2015;48:183-187. 3. Lim HW, Collins SAB, Resneck JS Jr, et al. The burden of skin disease in the United States. J Am Acad Dermatol. 2017;76: 958-972.e2.