Peter J. Green

Prevention of Alopecia in Medical and Interventional Chemotherapy Patients

Background: Chemotherapy-induced alopecia is one of the most distressing side effects of cancer treatment. Although there have been a number of investigated strategies to reduce this, there is no standard of care for treatment. Objective: This review aims to summarize the relevant evidence for the treatments available for chemotherapy-induced alopecia. Methods: A literature search using PubMed and the MEDLINE subengine was completed. The terms “chemotherapy,” “alopecia,” “quality of life,” and “strategies” were used, and articles from the last 10 years were considered. The pediatric population was not investigated. Results: Physical therapies for alopecia prevention have shown some promise but range from insufficient to detrimental depending on the type of cancer. Cold caps may be more effective than tourniquets and may be associated with fewer metastatic events. Pharmacologic therapies, both immunomodulators and growth factors, have stood the test of several trials to date. In particular, cyclosporine has been shown either to prevent alopecia or promote hair growth during a chemotherapy regimen. Conclusion: Although the evidence is not yet overwhelming, it is becoming clear that a combination of mechanical and chemical interventions may help compensate for the downfalls of either therapy alone.

Lupus miliaris disseminatus faciei with extrafacial involvement in a 17-year-old white girl.

Background: Lupus miliaris disseminatus faciei (LMDF) is a benign condition characterized by a papular eruption located in the central face. Histologic studies of the papules show granulomatous infiltrates with central necrosis. The condition is self-limited and usually resolves within 1 to 2 years yet can be cosmetically debilitating, given the location and potential for scarring. Granulomatous periorificial dermatitis similarly affects the face with granulomatous lesions and may overlap clinically with LMDF. Conclusion: This report highlights the challenge in differentiating and treating uncommon granulomatous facial dermatoses.

AL Amyloidoma of the Skin/Subcutis: Cutaneous Amyloidosis, Plasma Cell Dyscrasia or a Manifestation of Primary Cutaneous Marginal Zone Lymphoma?

It is unclear whether AL amyloidoma of the skin/subcutis represents a distinct entity, an indolent precursor of systemic amyloidosis, or a manifestation of cutaneous marginal zone lymphoma (cMZL). We collected 10 cases of cutaneous AL amyloidoma in order to better characterize the clinicopathologic features of this elusive entity (M:F=4:6; median age: 62.5 y, range: 31 to 82 y). Nine patients had a solitary nodule or plaque on the lower extremity (n=7), upper extremity (n=1), or chin (n=1). One patient had an AL amyloidoma on the right thigh and a second lesion on the right arm showing histopathologic features of cMZL without amyloid deposits. Clinical investigations excluded relevant systemic disease in all cases. Microscopically, dermal/subcutaneous deposits of amyloid were associated with sparse to moderate perivascular infiltrates of lymphocytes and monotypic plasma cells (7 with kappa and 3 with lambda light chain restriction). The plasma cells expressed CD56 in one of 9 studied cases. One case was characterized by a t(14;18)(q32;q21)/IGH-MALT1 translocation. Follow-up was available in 8 cases. All remain systemically well after a median time of 86.5 months (range: 40 to 144 mo). Local recurrence of disease was observed in 3 patients. A fourth patient presented with a cMZL without amyloid deposits 8 years after excision of the cutaneous AL amyloidoma. Although our series is small, careful categorization and follow-up of the cases, together with updated information in the literature, show clinical and biological links between AL amyloidomas of the skin/subcutis and cMZL, suggesting that at least a subset of cutaneous AL amyloidoma may represent an unusual manifestation of cMZL (cutaneous mucosa-associated lymphoid tissue lymphomas).

Necrobiotic xanthogranuloma associated with necrotizing scleritis.

A 57-year-old man presented to the ophthalmology clinic with a red right eye. He denied pain, diplopia, tearing, and blurred vision. His medical history included asymptomatic annular plaques on the trunk and extremities for at least a decade. Ophthalmological examination revealed a necrotizing scleritis of the right eye. Examination of the skin demonstrated variable sized annular plaques with central atrophy, some with prominent indurated border and yellow discoloration. No periorbital lesions were present. The ocular lesion rapidly progressed and areas of scleral melting developed in the right eye, which eventually required a scleral patch graft. The left eye also developed necrotizing scleritis with areas of scleral melting. Two sets of skin biopsies were performed a few weeks apart. An initial set of skin punch biopsies revealed extensive palisading granulomatous inflammation throughout the dermis, extending into the subcutis. The accompanying perivascular mononuclear infiltrate contained the collections of plasma cells. Scattered multinucleated giant cells were noted. The possibility of necrobiosis lipoidica diabeticorum was suggested. Subsequent skin biopsies showed more prominent and extensive necrobiosis, raising the possibility of necrobiotic xanthogranuloma. Protein electrophoresis was performed, which revealed an IgG λ monoclonal protein.

Itchy scaly bumps on trunk and extremities: challenge.

Case A 33-year-old man was seen in dermatology clinic for a markedly pruritic scaly eruption present for 1 year on the extremities and trunk. The patient had longstanding diabetes mellitus and was undergoing peritoneal dialysis for the last 2 years. Ultra potent topical steroids had been prescribed by another dermatologist 6 months before with no improvement in findings or symptoms. He was referred by the transplantation team for diagnostic clarification of skin findings given consideration for simultaneous kidney pancreas transplant. His past medical history was also significant for hemorrhagic retinopathy, mild peripheral neuropathy, and atrial septal defect repaired as a child. On physical examination, hyperkeratotic red-brown papules were most densely distributed on hairbearing areas of lower extremities, with individual lesions demonstrating a central keratotic plug (Fig. 1). Similar lesions were observed on the upper extremities and upper back, although not as numerous as observed on the legs. Lesion distribution was predominantly follicular, with evidence of excoriation, but no secondary infection. He was referred for UVB phototherapy given marked pruritus and extent of cutaneous involvement. A punch biopsy of skin was obtained from a representative lesion on the lower extremity, which revealed a dilated follicular infundibulum filled with keratinous and cellular debris. A focal area of the follicular epithelium was disrupted, and collagen fibers were identified entering the perforation site. (Figs. 2, 3).

The man with tight legs: challenge.

CASE REPORT A 57-year-old man attended a dermatologist because of progressive hardening of his skin, initially on the right arm and later on the lower legs. The process had recently resulted in limitation of movement of the right ankle and was impairing his ability to work as a tradesman. When seen by another dermatologist 4 years earlier, a skin biopsy from an indurated area on the right leg showed evidence of morphea, and a more recent review by a rheumatologist had uncovered a peripheral blood eosinophilia. He did not have Raynaud’s phenomenon, joint problems, or other systemic symptoms. His general medical history was significant for type II diabetes mellitus, hypertension, and a myocardial infarct 6 years earlier. On physical examination, the most striking abnormalities were observed on the lower legs (Fig. 1). The more severely affected right leg revealed circumferential thickening and induration of the skin extending from