Robert A. Lee

Treatment of hidradenitis suppurativa with biologic medications

Given the absence of significant improvement in the treatment of hidradenitis suppurativa (HS) with traditional medical and surgical therapies, biologics have piqued the interest of research investigators. The efficacy of biologics in the treatment of inflammatory conditions like psoriasis and rheumatoid arthritis is well-documented. More recently, success with biologics has been demonstrated in atopic dermatitis, another dermatological condition associated with inflammatory states. Researchers have begun to probe the utility of biologic agents in less prevalent conditions that feature inflammation as a key characteristic, namely, hidradenitis suppurativa. Five agents in particular adalimumab, anakinra, etanercept, infliximab, and ustekinumab, have been explored in the setting of HS. Results to date put forward adalimumab and infliximab as biologic treatments that can safely be initiated with some expectant efficacy. Other biologic agents require more rigorous examination before they are worthy of addition to the treatment armamentarium.

Single treatment of non‐melanoma skin cancers using a pulsed‐dye laser with stacked pulses

Non‐melanoma skin cancers are the most common cause of cancer worldwide. Within this grouping, the most common skin cancer is basal cell carcinoma (BCC) followed by squamous cell carcinoma (SCC). Recent evidence has shown that BCCs can be cleared by a pulsed‐dye laser after multiple treatments using a single pass setting. Given the necessity for multiple treatments in the prior studies, we sought to determine whether tumor clearance could instead be achieved using a single treatment of the pulsed‐dye laser in a stacked pulse setting.

Management of Pilomatrix Carcinoma: A Case Report of Successful Treatment with Mohs Micrographic Surgery and Review of the Literature

Pilomatrix carcinoma is a rare malignant variant of pilomatrixoma, a cutaneous adnexal tumor that originates from hair matrix cells. Reports of similar lesions date as far back as 1927, but Lopansri and Mihm first defined the tumor in 1980 as an aggressive form of pilomatrixoma with a tendency toward recurrence. Pilomatrix carcinoma has also been referred to in the literature as pilomatrical carcinoma, malignant pilomatricoma, malignant pilomatrixoma, matrical carcinoma, and calcifying epitheliocarcinoma of Malherbe. Lesions occur most commonly on severely sun-damaged skin and may arise through transformation of a pilomatrixoma or as a solitary, newly formed entity. These tumors are most frequently located on the head, neck, and back, although occurrence on the anterior trunk and upper and lower extremities has also been reported. Pilomatrix carcinoma manifests clinically as an asymptomatic mass that may resemble basal cell carcinoma, epidermal cyst, trichilemmal cyst, or pilomatrixoma. Lesions may arise over a period of months to many years, with a propensity for aggressive local recurrence and metastasis. Given its rarity, an optimal treatment regimen for pilomatrix carcinoma has not been established. Recurrence rates of >50% have been found after simple excision, with follow-up time ranging from a few months to many years. Most publications advocate wide local excision, with recommended margins varying between 5 mm and 2 cm. Mohs micrographic surgery (MMS) has been shown to be the most effective therapy for a number of rare malignant cutaneous tumors, including rare adnexal tumors such as sebaceous carcinoma and microcystic adnexal carcinoma. In 2004, Sable and Snow first reported on the successful management of pilomatrix carcinoma using MMS, with no evidence of recurrence at follow-up 5 months later. Given the tendency for aggressive local recurrence of pilomatrix carcinoma and the superior margin control available with MMS, MMS may represent an ideal treatment modality for this rare condition. Here, we report on a second case of pilomatrix carcinoma treated with MMS and provide a comprehensive literature review of the epidemiology, pathogenesis, clinical presentation, histopathologic findings, prognosis, follow-up, and management options for pilomatrix carcinoma.

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.

Epidermal multinucleated giant cells are not always a histopathologic clue to a herpes virus infection: multinucleated epithelial giant cells in the epidermis of lesional skin biopsies from patients with acantholytic dermatoses can histologically mimic a herpes virus infection

Background: Multinucleated giant cells in the epidermis can either be epithelial or histiocytic. Epithelial multinucleated giant cells are most often associated with herpes virus infections. Purpose: To review the histologic differential diagnosis of conditions with epithelial and histiocytic multinucleated giant cells—since multinucleated giant cells in the epidermis are not always pathognomonic of a cutaneous herpes virus infection—and to summarize dermatoses in which herpes virus infection has been observed to coexist. Methods: Two individuals with acantholytic dermatoses whose initial lesional skin biopsies showed multinucleated epithelial giant cells suggestive of a herpes virus infection are reported. Using the PubMed database, an extensive literature search was performed on multinucleated giant cell (and epidermis, epithelial, and histiocytic) and herpes virus infection. Relevant papers were reviewed to discover the skin conditions with either multinucleated giant cells in the epidermis or coincident cutaneous herpes virus infection. Results: Initial skin biopsies from patients with either pemphigus vulgaris or transient acantholytic dermatosis mimicked herpes virus infection; however, laboratory studies and repeat biopsies established the correct diagnosis of their acantholytic dermatosis. Hence, epidermal multinucleated giant cells are not always a histopathologic clue to a herpes virus infection. Indeed, epithelial multinucleated giant cells in the epidermis can be observed not only in the presence of infection (herpes virus), but also acantholytic dermatoses and tumors (trichoepithelioma and pleomorphic basal cell carcinoma). Histiocytic multinucleated giant cells in the epidermis can be observed in patients with either giant cell lichenoid dermatitis or lichen nitidus of the palms. Conclusions: Epithelial and histiocytic multinucleated giant cell can occur in the epidermis. Keratinocyte-derived multinucleated giant cells are most commonly associated with herpes virus infection; yet, they can also be observed in patients with skin tumors or acantholytic dermatoses. Cutaneous herpes simplex virus infection can coexist in association with other conditions such as acantholytic dermatoses, benign skin tumors, bullous disorders, hematologic malignancies, inflammatory dermatoses, and physical therapies. However, when a herpes virus infection is suspected based upon the discovery of epithelial multinucleated giant cells in the epidermis, but either the clinic presentation or lack of response to viral therapy or absence of confirmatory laboratory studies does not support the diagnosis of a viral infection, the possibility of a primary acantholytic dermatosis should be considered and additional lesional skin biopsies performed. Also, because hematoxylin and eosin staining is not the golden standard for confirmation of autoimmune bullous dermatoses, skin biopsies for direct immunofluorescence should be performed when a primary bullous dermatosis is suspected since the histopathology observed on hematoxylin and eosin stained sections can be misleading.

Lymphedematous verrucous changes simulating squamous cell carcinoma in long-standing hidradenitis suppurativa.

Background  Hidradenitis suppurativa (HS) is a relatively common condition marked by abscesses, sinus tracts, and scarring in intertriginous regions of the body. Lymphedema is an under‐recognized consequence of chronic inflammation in the setting HS.

Prurigo Pigmentosa: Literature Review

Prurigo pigmentosa, also referred to as Nagashima’s disease, is a rare inflammatory skin condition of unknown etiology. It typically presents as pruritic erythematous papules, papulovesicles, and vesicles appearing in a reticular pattern on the back, chest, or neck. The histological features of prurigo pigmentosa vary according to the stage of the disease. Early-stage disease is characterized by a superficial perivascular infiltrate of neutrophils; spongiosis and necrotic keratinocytes commonly appear in later stages. The etiology of prurigo pigmentosa has yet to be determined. Oral minocycline is usually the first-line therapy for prurigo pigmentosa. However, doxycycline, macrolide antibiotics, and/or dapsone (diaminodiphenyl sulfone) may be indicated for some patients. We describe the key features of prurigo pigmentosa, including the epidemiology, clinical and histologic presentation, differential diagnosis, postulated pathogenesis, and treatment options for this condition.

Acantholytic dyskeratotic acanthoma: case report and review of the literature

Background: Focal acantholytic dyskeratosis has been described as an incidental finding and as a clinically distinct lesion. In both situations, a dimorphic histologic pattern is observed: acantholysis and dyskeratosis. Solitary, non-genital lesions displaying such pathology have been difficult to classify. Clinical and pathological characteristics of acantholytic dyskeratotic acanthomas are described. Methods: The features of a patient with solitary, non-genital, acantholytic dyskeratotic acanthoma are presented and the literature on acantholytic dyskeratotic acanthomas is reviewed. Using PubMed the following terms were searched and relevant citations assessed: acantholysis, acanthoma, cutaneous, dyskeratosis, nail, warty. Results: We identified 30 cutaneous acantholytic dyskeratotic acanthomas, including our patient, most often found on the trunk and mimicking basal cell carcinoma, and three subungual acantholytic dyskeratotic acanthomas of the thumb, which mimicked onychopapilloma. Conclusion: Acantholytic dyskeratotic acanthomas are clinically and pathologically distinct lesions, which may morphologically present as either truncal plaques or subungual longitudinal erythronychia.

Desmoplastic trichilemmoma--a report of successful treatment with Mohs micrographic surgery and a review and update of the literature.

Desmoplastic trichilemmoma (DT) is a rare benign histologic variant of trichilemmoma, a benign growth of the pilosebaceous follicle’s outer sheath. Headington and French first described trichilemmoma in 1962. The presence of irregular cords and epithelial cell nests in a prominent densely sclerotic collagenous stroma in its center differentiate DT, which Hunt and colleagues described in 1990, from trichilemmoma.

Atypical eruption but still Still's: case report and review of the literature.

Adult-onset Still’s disease (AOSD) is a systemic inflammatory condition characterized by spiking fevers, leukocytosis, arthralgia, and transient/typical skin rash. Approximately 40 cases of persistent pruritic papules and plaques have been described in the literature thus far (Table 1). “Persistent dermal plaque” was initially proposed by Kaur et al. to describe erythematous confluent papules that coalesced to form large irregular plaques, which was distinct from the evanescent rash. In 1995, Lee et al. called it “Persistent papules and plaques of AOSD,” and described its unique clinical and histologic features. We describe a case where the persistent rash responded to methotrexate and will review the clinical and pathologic findings of the previously reported cases. Recognition of this clinical variant is crucial for the early diagnosis of AOSD, as it might imply persistent disease activity and the need for more aggressive treatment.