Roger Haber

Bullous Pemphigoid Associated With Linagliptin Treatment

and dysgeusia than the continuous regimen. Similarly, the muscle cramps and dysgeusia in the present patients resolved within 1 month after interrupting the vismodegib regimen. Although pharmacokinetic studies have shown suboptimal efficacy and similar incidence and severity of adverse effects when vismodegib, 150 mg, was used once weekly or 3 times weekly, no studies to our knowledge have investigated the efficacy of continuous daily doses with drug breaks in between.3 We found a mean of 1.4 new surgically eligible BCCs per year per patient undergoing intermittent therapy, which is comparable to the 2.0 new surgically eligible BCCs per year per patient found by Tang et al1 in patients undergoing a standard continuous daily regimen. Vismodegib resistance occurs in patients who undergo continuous vismodegib dosing.4 The frequency of resistance in patients who undergo an intermittent form of treatment is largely unknown. Combination therapy with hedgehog pathway inhibitors downstream of smoothened, such as itraconazole and arsenic trioxide, provide opportunities to increase efficacy and possibly reduce the incidence of resistance.5,6

Comparison of microwave ablation, botulinum toxin injection, and liposuction-curettage in the treatment of axillary hyperhidrosis: A systematic review

Background: Primary focal axillary hyperhidrosis is a disorder of excessive sweating that can strongly impact quality of life. Objective: The objective if this study was to compare microwave ablation (MA), botulinum toxin (BT) injection, and liposuction-curettage (LC) in the treatment of primary axillary hyperhidrosis based on subjective and objective criteria. Methods: A systematic review of the literature published in French or English between 1 January 1991 and 1 February 2015 was completed using PubMed and Embase databases. Results: 16 of 775 articles were selected based on relevance and criteria of inclusion and exclusion. The three methods proved to be efficient and safe; however, MA and BT had better results when compared to LC in the short term. Both MA and LC showed longer lasting results when compared to BT. However, in the long term, MA was superior to LC. Conclusion: MA, LC, and BT injections are safe and efficient minimally invasive alternatives for the treatment of axillary hyperhidrosis. Well-designed randomized controlled trials are needed to further compare the efficacy of these techniques.

Pediatric pyoderma gangrenosum: a systematic review and update

Pyoderma gangrenosum (PG) is a sterile neutrophilic disorder that rarely affects children. Clinical, epidemiological, and therapeutic data on pediatric PG is poor as there are many newly reported associated diseases and drugs. This paper aims to review all recent available data on pediatric PG. A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. A total of 132 articles were included in the review. The most commonly reported underlying diseases in pediatric PG are inflammatory bowel diseases followed by hematologic disorders, vasculitis, immune deficiencies and Pyogenic Arthritis, Pyoderma gangrenosum and Acne (PAPA) syndrome. More than half of the cases occur with no underlying disease. The most frequently reported clinical presentation is multiple disseminated ulcers. Treatment should be tailored according to the underlying etiology. It includes systemic steroids, corticosteroid sparing agents such as dapsone and cyclosporine, and TNF‐alpha inhibitors such as adalimumab and infliximab. Response to treatment is high with cure rates reaching 90%. A high index of suspicion and a thorough workup are mandatory in the management of pediatric PG.

Laser treatment of onychomycosis: beware of ring block anesthesia!

Laser treatment of onychomycosis is a novel treatment modality that improves the cosmetic appearance of the nails. Although no study has yet proved the efficacy of this treatment for onychomycosis, and although it is still not cleared by the FDA for this indication, it has emerged as a safe and effective technique that might enable from prescribing antifungal therapies, thus preventing potential drug interactions and systemic effects. Reported adverse effects ranged from a mild burning sensation to a complete nail loss due to overheating. Most patients only reported mild or no discomfort. In our practice, we experienced two situations of burning after a single laser session. A 57-year-old patient who received a treatment session for his toenail onychomycosis using a novel 0.65-ms pulsed Nd-YAG 1064-nm laser (PinPointe FootLaser, pulse duration 450 μs, PAV 6 W, fluence 200 mJ, frequency 30 Hz). He insisted on having a ring block anesthesia for the toenail to avoid any pain even though it is not recommended in our daily practice. The following day, he presented with excruciating pain, edema, oozing, erythema and a burning sensation (Fig. 1). Similar findings were noted in the second patient. Laser treatment of onychomycosis is based on photothermolysis [1, 2] which relies on a specific wavelength of light to target a precise tissue. The light absorbed by the target area generates sufficient energy to damage the target area while sparing the surrounding area [1]. It is known that fungi are heat sensitive above 55 °C which inhibits their growth and causes cell damage and death [3, 4]. The aim of laser treatment of onychomycosis is to heat the nail bed to temperatures required to disrupt fungal growth (approximately 40– 60 °C) and at the same time avoid pain and necrosis to surrounding tissues [1]. However, overheating could result in nail loss. Therefore, it is recommended to avoid anesthesia so that the patient can feel the increased heat and pain, forcing the operator to pause for some seconds and allowing the heat to dissipate [5]. Our two reported cases demonstrate the value of this recommendation. To reduce pain and avoid cutaneous damage, laser energy format should be either pulsed to allow the dissipation of heat by the tissue through its superior thermal conduction or delivered at a moderate energetic level to prevent tissue damage [2]. Patients should be aware of this rising concern as well as clinicians who should learn how to minimize the risk of adverse effects, sparing the patient possible and irreversible nail damage. Further studies are needed to define the safest and most effective treatment parameters. * Roger Haber roger.haber@net.usj.edu.lb

Splinter hemorrhages of the nails: a systematic review of clinical features and associated conditions

Splinter hemorrhages (SHs) of the nails represent a frequent although not specific clinical finding that has been associated with conditions of varying severity. However, to date, there is no single report of their characteristics and etiologies. The aim of this study is to guide clinical practice by reviewing all of the data concerning SH of the nails that have become available since the first description of this condition was published in 1923, with particular reference to all clinical features, associated medical conditions, pathogenesis, and necessary workup. PubMed and EMBASE were searched using the keywords “splinter” AND “hemorrhage*”; the only articles excluded were those studying SHs of the retina. Splinter hemorrhage is a frequent nail disorder that may be idiopathic, drug‐induced, or a sign of a dermatological disease, such as psoriasis and lichen planus, or a wide range of systemic disorders, the most important of which are infections and vasculitis. Clinicians and dermatologists should be aware of all the clinical features of both SH and associated medical conditions.

Management of digital mucous cysts: a systematic review and treatment algorithm

Digital mucous cysts (DMC) are benign, highly recurrent lesions of the digits. To date, there is still no treatment agreement on the treatment of DMC. Herein, we review available data on treatment modalities, including both surgical and nonsurgical techniques, and to provide a practical algorithm for the management of DMC. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane databases. Articles studying the management of DMC were included in this review. A total of 40 articles were included in the review. The five most frequently used treatments for DMC were surgery (n = 849), expression of cyst content (n = 132), sclerotherapy (n = 119), corticosteroid injection (n = 108), and cryotherapy (n = 103). Surgery yielded the highest cure rate among all treatment modalities (95%) compared to sclerotherapy (77%), cryotherapy (72%), corticosteroid injection (61%), and expression of cyst content (39%) (P < 0.001). Surgery should be considered as the first‐line treatment for DMC. Second‐line treatments include sclerotherapy and cryotherapy. Third‐line treatments include corticosteroid injections, expression of cyst content, and less‐studied modalities. Surgery showed the highest cure rates. Future adequately designed randomized controlled trials are warranted to compare different treatment modalities.

Lamotrigine-induced hypersensitivity syndrome with histologic features of cd30+ lymphoma

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome or drug-induced hypersensitivity syndrome (DIHS) is a severe adverse drug reaction. It can present with clinical, paraclinical, and histological findings mimicking skin and/or systemic lymphomas. We report the first case of a lamotrigine-induced DRESS with histologic features of a cutaneous CD30+ lymphoma. The patient responded well to a tapering course of oral steroids. This case highlights the atypical presentation of a lamotrigine-induced DRESS/DIHS in the presence of a cutaneous and a lymph node CD30 + lymphocytic infiltrate mimicking systemic lymphoma. Pathologists and clinicians must be aware of this “lymphomatous” presentation of drug reactions.

Management of Chondrodermatitis Nodularis Helicis: A Systematic Review and Treatment Algorithm.

BACKGROUND Chondrodermatitis nodularis helicis (CNH) is an idiopathic benign inflammatory painful condition of the ear. Still, to date, no study has yet evaluated nor compared treatments regarding their safety and efficacy. OBJECTIVE The objective of this study is to review all available treatment modalities of CNH that were described in the literature, compare their efficacy and propose a treatment algorithm. METHODS AND MATERIALS A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. Articles studying the management of CNH that reported data on the cure rates were included in this review. RESULTS A total of 29 studies were included in the review. The 3 most commonly reported treatments for CNH are surgery, pressure relief, and topical nitroglycerin. Surgery has higher cure rate (82%) compared with pressure relief treatment (37%) or nitroglycerin (51%) (p < .0001). Surgery should be considered as the first-line treatment for CNH. Second-line treatments include nonsurgical therapies, particularly nitroglycerin and pressure relief techniques, alone or in combination. Third-line treatments include newer or less studied methods. CONCLUSION Among the treatment modalities, surgery showed the highest cure rates. Adequately designed randomized controlled trials are warranted to compare newer therapeutic methods.

Intractable Localized Inguinal Pruritus as a Sign of Primary Hyperparathyroidism

Generalized pruritus is a well-known complication of primary hyperparathyroidism. We present the first case of primary hyperparathyroidism presenting as a severe localized inguinal pruritus. Pruritus completely resolved after subtotal parathyroidectomy suggesting that intractable cutaneous symptoms like pruritus might be added to the current approved indications of parathyroidectomy in primary hyperparathyroidism. This study also discusses the pathophysiology of pruritus in hyperparathyroidism.

First Case of Maffucci Syndrome Associated with Multiple Epidermal Nevi

Maffucci syndrome is a congenital non hereditary disease caused by a mesodermal dysplasia in multiple regions of the body and resulting in both vascular and cartilaginous abnormalities. We describe the first case of Maffucci syndrome associated with multiple epidermal nevi suggesting a possible genetic link.