Stephanie W. Liu

The effects of alcohol and drug abuse on the skin

Skin changes associated with alcohol and drug abuse can be the earliest clinical manifestation of these disorders. The signs associated with these conditions may be distinctive and easily recognizable. Alcohol abuse can present with jaundice, pruritus, hyperpigmentation, and urticaria. Commonly associated vascular changes include spider telangiectasias, angiomas, caput medusas, flushing, and palmar erythema. Disease states related to alcohol abuse include psoriasis, porphyria cutanea tarda, and nutritional deficiencies. Alcohol abuse may predispose to the development of carcinomas of the skin, oropharynx, liver, pancreas, and breast. Cutaneous signs of drug abuse include skin granulomas, ulcerations, and recurrent infections. Specifically, oral disease and tooth decay are examples of stigmata often associated with methamphetamine abuse, a popular and inexpensive drug now on the scene. By being cognizant of these cutaneous markers of alcohol and drug abuse, dermatologists are often in the unique position of being able to recognize these changes, prompting early diagnosis and intervention, hopefully resulting in a better clinical outcome for these troubled patients and their families.

Dermatomyositis Induced by Anti–Tumor Necrosis Factor in a Patient With Juvenile Idiopathic Arthritis

IMPORTANCE Biologic therapies, including anti-tumor necrosis factor (TNF) agents, are increasingly used to treat a variety of autoimmune diseases. Paradoxically, these agents have been reported to induce some of the very diseases they were designed to treat, including dermatomyositis (DM). We describe the first case of anti-TNF-associated DM without muscle involvement presenting in an adult patient with a history of arthritis since childhood. This cutaneous eruption recurred after rechallenge with an alternate anti-TNF agent. OBSERVATIONS A 46-year-old man with juvenile idiopathic arthritis developed a pruritic cutaneous eruption while receiving etanercept. Given concern about a drug-induced eruption, etanercept therapy was discontinued and the cutaneous findings improved. However, after rechallenge with adalimumab, he developed similar findings consistent with the skin manifestations of DM. After discontinuation of all anti-TNF drug therapy and the addition of methotrexate sodium, his eruption improved. CONCLUSIONS AND RELEVANCE Because the use of these agents is increasing, practitioners should be aware of the possibility of anti-TNF-induced autoimmune disorders, including DM. The case described herein is unique in that anti-TNF-induced autoimmune disease occurred in a patient with existing arthritis since childhood and recurred with rechallenge, adding further evidence to support the existence of anti-TNF-induced DM.

The Brigham Scalp Nail Inverse Palmoplantar Psoriasis Composite Index (B-SNIPI): A Novel Index to Measure All Non-plaque Psoriasis Subsets

Psoriasis is a chronic inflammatory disease that encompasses a large spectrum of clinically distinct subtypes. Although chronic plaque psoriasis is reported as the most common form of psoriatic skin disease, there is growing evidence that other variants including scalp, nail, inverse, and palmoplantar psoriasis are prevalent, undertreated, and associated with significant impairment in quality of life. Currently, the Psoriasis Area and Severity Index (PASI) is the standard to assess psoriasis severity as well as response to treatment; however, the PASI has several limitations. In response to this need and as a complementary objective measure to the PASI, we created the Brigham Scalp Nail Inverse Palmoplantar Psoriasis Composite Index (B-SNIPI), based on patient-surveyed, patient-reported outcomes equally weighted with physician assessment of disease activity. Herein we summarize the B-SNIPI as presented at the 2013 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

Master Case Presentation: Idiopathic hemi-facial lipoatrophy treated with autologous fat transfer

Facial lipoatrophy can be socially disfiguring, often prompting patients to seek correction. A variety of agents are used to treat facial lipoatrophy, but the quest for the ideal agent remains elusive. We present a case of non‐HIV associated, idiopathic hemi‐facial lipoatrophy successfully treated with autologous fat transfer (ATF). Because ATF has no complications from antigenicity, it is a safe and cost‐effective treatment option for patients with non‐HIV associated cases of facial lipoatrophy and abundant donor tissue.

Effect of sunitinib on renal cell carcinoma cutaneous metastasis

metastasis A 64-year-old man with a history of stage IV renal cell carcinoma (RCC) involving the right kidney and thalamus underwent gamma knife irradiation for the metastatic thalamic lesion, cytoreductive right radical nephrectomy, and ipsilateral adrenalectomy for his renal disease. At the 12-week follow-up, he presented with an asymptomatic growing papule on the right lower lip (Fig. 1a). Physical examination revealed a dome-shaped, translucent, 8-mm papule with telangiectasias. Biopsy of the cutaneous lesion showed large epithelial cells with acantholytic features, eosinophilic cytoplasm, prominent nucleoli, and variable hyperchromasia with extensive areas of necrosis and hemorrhage (Fig. 1c). Immunohistochemical staining for vimentin, CD10, and cytokeratin was positive, consistent with cutaneous metastasis of RCC. The patient was started on sunitinib maleate (Sutent , Pfizer, LaJolla, CA, USA), an oral tyrosine kinase inhibitor of vascular endothelial growth factor receptor (VEGFR-1–3), RET, Flt-3, c-kit, and platelet-derived growth factor receptor (PDGFR-aB). During the first cycle, the papule decreased in size to near-complete resolution (Fig. 2a). Following the second cycle, there was additional improvement of his metastatic pulmonary disease (Fig. 1b, before treatment; Fig. 2b, after treatment). Cutaneous metastases from RCC are rare findings with an estimated incidence of 3.4%. They are usually a late manifestation of disease, and are associated with a poor prognosis and visceral recurrence. The median survival of patients diagnosed with cutaneous metastasis from RCC has been estimated at less than 8 months. Lesions may be asymptomatic, appearing as papules, plaques, or nodules, most commonly in the head and neck region. Lesion color may vary depending on the amount of vascularization and hemosiderin deposition within the dermis. The differential diagnosis may include hemangiomas, pyogenic granulomas, Kaposi’s sarcoma, and cutaneous lymphoma. Cutaneous

Idiopathic hemi-facial lipoatrophy treated with autologous fat transfer.

Facial lipoatrophy can be socially disfiguring, often prompting patients to seek correction. A variety of agents are used to treat facial lipoatrophy, but the quest for the ideal agent remains elusive. We present a case of non‐HIV associated, idiopathic hemi‐facial lipoatrophy successfully treated with autologous fat transfer (ATF). Because ATF has no complications from antigenicity, it is a safe and cost‐effective treatment option for patients with non‐HIV associated cases of facial lipoatrophy and abundant donor tissue.

Development and Pilot Testing of the Cutaneous Lupus Screening Tool

IMPORTANCE Patients with cutaneous lupus erythematosus (CLE) experience significant morbidity and poor quality of life. In the absence of a dermatologists examination, no reliable tool exists to confirm whether a patient has CLE for use in epidemiologic studies. OBJECTIVE To determine whether the Cutaneous Lupus Screening (CLUSE) tool can detect cases of CLE by measuring its performance in individuals with dermatologist-diagnosed CLE compared with individuals without CLE. DESIGN, SETTING, AND PARTICIPANTS The CLUSE tool is a novel, self-administered questionnaire with 15 closed-ended questions derived from the Delphi method. It includes features of disease validation for CLE as well as its most common phenotypes. This pilot study was administered during a 1-year period (July 1, 2011, to June 30, 2012) in outpatient dermatology clinics at an academic medical center. Data analysis was performed July 1, 2012, to November 30, 2013. Participants were individuals 18 years or older who had a definitive diagnosis of CLE or any other non-CLE dermatologic condition as established by a board-certified dermatologist. Eligible patients were recruited consecutively, and no individual approached declined to participate. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of the individual questions from the CLUSE tool in predicting CLE, comparisons between summary scores for the dichotomous questions between the CLE cases and non-CLE controls, and 9 scoring algorithms that assign a diagnosis of CLE and its subtypes depending on an individuals response to each question. RESULTS A total of 133 patients were given the CLUSE tool; 16 participants were excluded. Responses from 117 individuals were collected for analysis and included 24 CLE cases and 93 non-CLE cases. In the 117 questionnaires analyzed, mean (SD) and median (interquartile range) CLUSE scores differed in the CLE (5.6 [2.1] and 5.5 [3-10], respectively) vs non-CLE (0.96 [1.6] and 0 [0-7], respectively) groups (all P < .001). Of the 9 algorithms, algorithm 9, used for diagnosing CLE regardless of subtype, demonstrated the highest sensitivity (87.5%) and high specificity (96.8%). CONCLUSIONS AND RELEVANCE A combination of questions and representative photographs can ascertain cases of CLE with high sensitivity and specificity. The CLUSE tool is a brief, self-administered questionnaire with low respondent burden used for the identification of CLE. In the future, this questionnaire will be administered to large, established patient databases to gather epidemiologic data on this disease.

Master Case Presentation: Idiopathic hemi-facial lipoatrophy treated with autologous fat transfer: Autologous fat transfer

Facial lipoatrophy can be socially disfiguring, often prompting patients to seek correction. A variety of agents are used to treat facial lipoatrophy, but the quest for the ideal agent remains elusive. We present a case of non‐HIV associated, idiopathic hemi‐facial lipoatrophy successfully treated with autologous fat transfer (ATF). Because ATF has no complications from antigenicity, it is a safe and cost‐effective treatment option for patients with non‐HIV associated cases of facial lipoatrophy and abundant donor tissue.