Steven A. Nelson

Relevance and Avoidance of Skin-Care Product Allergens: Pearls and Pitfalls

Patch testing can be particularly rewarding when skin-care product allergens are identified. Careful determination of relevance, followed by careful education regarding allergen avoidance, can result in dramatic clinical improvement. Several common clinical scenarios are reviewed with a focus on pragmatic solutions to heighten positive patient outcomes.

Accuracy and confidence in the clinical diagnosis of basal cell cancer using dermoscopy and reflex confocal microscopy

Diagnosis of suspected basal cell carcinoma (BCC) is typically confirmed with incisional biopsy before referral to final surgery.

Sebaceous carcinoma in solid organ transplant recipients

Though a rare tumor, sebaceous carcinoma is relatively well‐described in immunocompetent patients, in whom it often occurs in a periorbital distribution where it has an overall poor prognosis with a high metastasis rate. The effect of transplant‐related immunosuppression on the development of sebaceous carcinoma and its outcomes has not been characterized.

The Prognostic Value of Inositol Polyphosphate 5-Phosphatase in Cutaneous Squamous Cell Carcinoma

Background: Inositol polyphosphate 5‐phosphatase (INPP5A) has been shown to play a role in development and progression of cutaneous squamous cell carcinoma (cSCC). The goal of the current study was to explore the prognostic value of INPP5A expression in cSCC. Methods: A total of 189 cases of actinic keratosis and SCC in 174 patients were identified; clinical and outcome data were abstracted, histopathology was rereviewed, and immunohistochemical staining and interpretation was performed for INPP5A. Results: The majority of tumors (89.4%) had an INPP5A score of 2 or 3. No patients had complete loss of INPP5A. Tumors with an INPP5A score of 1 were more likely to be intermediate‐ to high‐risk tumors (Brigham and Womens Hospital stage ≥T2a 85.0% vs 23.7% [P < .0001]) characterized by a larger diameter (2.4 cm vs 1.3 cm [P = .0004]), moderate‐to‐poor differentiation (86.7% vs 17.6% [P < .0001]), and perineural invasion (37.5% vs 5.3%, [P < .0001]). An INPP5A score of 1 was associated with a worse 3‐year survival (a rate of 42.3% [hazard ratio, 2.81, P = .0006]) and a local metastasis rate of 48.0% (hazard ratio, 4.71; P < .0001). Conclusions: Low INPP5A scores are predictive of aggressive tumors and may be a useful adjunct to guide clinical management of cSCC.

Clinical and histopathologic features of paraneoplastic granuloma annulare in association with solid organ malignancies: A case–control study

Background Granuloma annulare (GA) is a granulomatous skin eruption rarely associated with cancer. We report seven cases of paraneoplastic GA in association with solid organ malignancy. Objective To compare the clinical and histopathological features of paraneoplastic GA to case‐matched controls of classic GA. Methods Retrospective chart and histopathological review of 7 individuals and 13 age‐ and sex‐matched controls. Paraneoplastic GA was defined as GA occurring within 6 months of the diagnosis of solid organ malignancy and/or persistent GA that resolved with cancer treatment. Results Most cases of paraneoplastic GA were associated with lung cancer (4/7). The clinical and histopathological features of paraneoplastic and classic GA were similar. Compared to classic GA, paraneoplastic GA cases were more often generalized disease (6/7 vs 6/13), refractory to treatment, and had a perivascular inflammatory cell infiltrate (5/7 vs 2/13). All cases of paraneoplastic GA that underwent definitive treatment of their cancer improved. Limitations Single‐institution, retrospective review with a small sample size. Conclusion Paraneoplastic GA is rare, similar to classic GA, and refractory to treatment. We advocate for age‐appropriate screening in individuals with GA that is nonresponsive to multiple lines of systemic treatment and evaluating patients with concerning signs or symptoms for an underlying neoplasm.

Gray-Brown Patches on the Face of a 62-Year-Old Woman

A 62-year-old woman with a history of rosacea and melasma presented with worsening gray-brown patches on the face. One year prior to presentation, the patient had a facial rash characterized by redness, burning, and minimal pruritus. The rash subsequently improved but resulted in dark patches covering the forehead, cheeks, and neck. She intermittently continued to experience mild facial erythema. No oral or other cutaneous lesions were reported. She previously tried topical tacrolimus, triamcinolone, flurandrenolide, azelaic acid, intermittent hydroquinone, and glycolic acid peels. Other than asthma treatment, she denied any significant history of systemic medications. Examination showed diffuse graybrown mottled hyperpigmented patches at the forehead, cheeks, and neck, sparing the central face, with focal red, poorly demarcated patches at the medial cheeks and glabella (Figure 1A). Close examination and dermoscopy showed blue-gray dots arranged in circles (Figure 1B). A punch biopsy specimen was obtained (Figure 1C).

Dermoscopic features of cutaneous Langerhans cell histiocytosis

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Cutaneous Papules, Hypercalcemia, and Osteolytic Bone Lesions

A 61-year-old Japanese American woman was hospitalized with recalcitrant hypercalcemia of 3 months’ duration. Physical examination showed generalized cutaneous papules. The patient also had osteolytic bone lesions that caused fractures. On admission, the calcium level was 17.5 mg/dL (to convert to mmol/L, multiply by 0.25), and the parathyroid hormone level was suppressed. Peripheral blood smear showed a slight absolute lymphocytosis with occasional atypical lymphocytes. A skin biopsy specimen revealed a dense dermal infiltrate of atypical T lymphocytes with strong CD25 expression, characteristic of human T-cell lymphotropic virus type 1 (HTLV-1)–associated adult T-cell leukemia/lymphoma (ATCLL). Serologic testing for HTLV-1 was subsequently shown to be positive. The HTLV-1 is endemic in Japan, the Caribbean, Central Africa, and the southeastern United States. Infection is transmitted by sexual contact, blood transfusion, or mother-to-child vertical transmission. The HTLV-1 genome is clonally integrated into the DNA of the lymphoma cells. The clinical differential diagnosis of the skin findings in this patient included generalized histiocytic disorders, leukemia cutis, and other types of lymphoma. The diagnosis is established through identification of the leukemia/lymphoma cells within the peripheral blood, skin, or other affected organs. The strong expression of CD25 by the lymphoma cells is a characteristic immunophenotypic finding. With conventional systemic chemotherapy regimens, the prognosis for patients with ATCLL is poor. Recent studies have examined other potentially more promising treatments, such as allogeneic stem cell transplant, alemtuzumab, denileukin diftitox, or antiviral agents. Although rare in the United States, ATCLL should be considered in patients from endemic areas who present with cutaneous lymphoid infiltrates, hypercalcemia, and osteolytic bone lesions.