Suguru Imaeda

Outcomes of Referral to Dermatology for Suspicious Lesions: Implications for Teledermatology

OBJECTIVES To determine the proportion of suspicious lesions referred by nondermatologists that are found to be malignant and the number of incidental skin cancers identified at the time of dermatology referral. DESIGN Retrospective cohort study. SETTING Veterans Affairs Connecticut Healthcare System. PATIENTS Four hundred patients referred by nondermatologists for skin lesions suspected of being malignant between January 1, 2006, through December 31, 2009. MAIN OUTCOME MEASURES Data collected included the type of referring provider, the final diagnosis by the dermatologist, and the number and type of incidental lesions. RESULTS Only 22.0% of the index lesions (ie, the lesions that prompted the referral) were found to be cancerous. In aggregate, 149 cancerous lesions were noted in 98 patients. However, only 88 (59.1%) were identified in the index lesion; 111 incidental lesions were biopsied by the consulting dermatologist, with 61 (55.0%) additional skin cancers identified. Twelve of the 61 incidental cancers (19.7%) were found in patients whose index lesion was clinically benign and was not biopsied. CONCLUSIONS Nondermatologists may benefit from focused educational initiatives on skin cancer detection, particularly the significance of the total body skin examination and the expectations for and limitations of teledermatology. A substantial proportion of malignant lesions was incidentally identified by the consulting dermatologist in addition to the primary lesion of concern. The use of teledermatology to assess a specific lesion of concern may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician. Therefore, teledermatology must not be used as a substitute for a total body skin examination.

Cross-comparison of patch test and lymphocyte proliferation responses in patients with a history of acute generalized exanthematous pustulosis

An adverse cutaneous reaction to a systemically administered drug may rarely manifest as acute generalized exanthematous pustulosis (AGEP). Several recent reports have documented positive patch test results in patients with a history of AGEP, while two have demonstrated drug-specific in vitro lymphocyte proliferative responses. These findings suggest that drug-specific T cells mediate AGEP. We describe two patients with a history of AGEP who each demonstrated positive patch test results specific for the inciting drug: Patient #1 to the antibiotic metronidazole, and Patient #2 to the calcium channel-blocker diltiazem. Histologic examination of biopsy specimens taken from the patch test sites of these patients revealed spongiotic dermatitis and perivascular lymphocytes consistent with a delayed-type hypersensitivity reaction, rather than demonstrating subcorneal neutrophilic pustules more typical of AGEP. In vitro testing by measuring peripheral T cell proliferative responses to chemically purified drug correlated with the clinical response. In a direct cross-comparison, patch test results were shown to correlate with in vitro lymphocyte proliferative responses in two patients with a history of AGEP to different drugs. These findings provide additional evidence that the pathogenesis of AGEP involves a T cell-mediated immune response.

Pneumocystis carinii pneumonia complicating methotrexate treatment of pityriasis rubra pilaris

From the Department of Dermatology, Yale University School of Medicine. Reprint requests: Leonard M. Milstone, MD, Professor of Dermatology, Yale University School of Medicine, Department of Dermatology, 333 Cedar St, 501 LCI, New Haven, CT 065208059. J Am Acad Dermatol 1998;39:276-8. Copyright

Subcutaneous histiocytoid Sweet's syndrome in a patient with myelodysplastic syndrome and acute myeloblastic leukemia

Subcutaneous histiocytoid Sweets syndrome is a rare variant of histiocytoid Sweets syndrome (SS). We present a 68‐year‐old woman with subcutaneous histiocytoid SS in association with refractory myelodysplastic syndrome transformed to acute myeloblastic leukemia (AML), status post induction chemotherapy and with persistent blasts (50%) in the bone marrow and blood, accompanied with neutropenia. The patient presented to the emergency room with fever and altered mental status. Clinical examination revealed approximately 20 scattered 0.5–2 cm, pink to pink‐purple non‐tender firm nodules on the legs and left arm. The differential diagnosis included Sweets syndrome (deep), leukemia cutis, infection, polyarteritis nodosa and erythema nodosum. Histopathologic examination of a biopsy from the left arm revealed a nodular infiltrate of neutrophils and histiocytoid mononuclear cells solely in the lobular compartment of the subcutaneous fat with focal areas of necrosis. Most cells in the infiltrate labeled with myeloperoxidase (MPO) including the histiocytoid cells. The cells were negative for CD34 and CD117. All special stains for microorganisms were negative. A diagnosis of subcutaneous histiocytoid SS was made. A subcutaneous histiocytoid SS should be suspected when a neutrophilic/histiocytoid panniculitis, occurring in the setting of myeloid disorders, is encountered and after exclusion of an infectious process and leukemia cutis.

Tofacitinib citrate for the treatment of refractory, severe chronic actinic dermatitis

CAD: chronic actinic dermatitis JAK: Janus kinase TCR: T cell receptor UV: ultraviolet INTRODUCTION Chronic actinic dermatitis (CAD) is an uncommon inflammatory dermatosis characterized by dermatitis involving ultraviolet (UV) lighteexposed skin with notable sparing of sun-protected areas. Rarely, spread of the exanthema to UV-protected areas of skin and even erythroderma with palmoplantar hyperkeratosis occurs. CAD typically afflicts men in the fifth decade of life or older. Although the pathophysiology remains unknown, it is thought that lymphocyte recognition of UV-induced neoantigens in the skin underlies this process. Furthermore, cross-reactivity to exogenous contact antigens may also be contributing, as allergic contact dermatitis to numerous allergens has been reported in more than 50% of affected individuals. Management involves strict photoprotection, topical corticosteroids, topical calcineurin inhibitors, prednisone, and immunomodulatory agents, often with only limited success. Herein, we report a case of severe CAD refractory to all common immunomodulatory agents that was successfully remitted with the Janus kinase (JAK)1/3 inhibitor tofacitinib citrate.

Treatment of melanoma in-transit metastases with combination intralesional interleukin-2, topical imiquimod, and tretinoin 0.1% cream

The treatment of in-transit and satellite melanoma metastases is challenging. Treatment options for these cutaneous and subcutaneous lesions include surgical excision, radiotherapy, isolated limb infusion/perfusion, electrochemotherapy, cryotherapy, laser therapy (pulsed dye or carbon dioxide), systemic treatment with interferon-α or interleukin-2 (IL-2), topical imiquimod, dinitrochlorobenzene, and intralesional immunotherapy with bacillus Calmette-Guerin vaccine, granulocyte macrophage colony-stimulating factor, IL-2, or talimogene laherparepvec.1 Response rates for these therapies are often suboptimal. Topical imiquimod has been used for the treatment of both melanoma in situ (in patients who are either poor surgical candidates or have positive margins after excision) and in-transit metastases.1, 2 There are reports of regression of locoregional melanoma metastases after topical imiquimod to cutaneous lesions.1, 2 Combination therapy using intralesional IL-2 together with topical imiquimod and tretinoin may increase the efficacy of IL-2.3 Here we report the case of a patient with in-transit metastatic melanoma treated with intratumoral IL-2 together with topical imiquimod and tretinoin cream.

Vegetative Plaques and Hemorrhagic Pustules

A man with a history of chronic renal insufficiency (baseline creatinine level, 2.8mg/dL) presented for evaluation of a painful forehead erythematous eruption and associated headache. (To convert creatinine to micromoles per liter, multiply by 88.4.) Three days prior to symptom onset he underwent a contrast-enhanced computed tomographic (CT) scan to evaluate abdominal pain. On the central forehead was a tender 5-cm reddish brown plaque composed of numerous coalescing vesicles and hemorrhagic pustules with intermixed serous and hemorrhagic crust. Similar vesicles and pustules were present on the nasal bridge and tip, the bilateral conchal bowls, and on the scalp (Figure, A). Two days later, the patient developed several 0.5to 1.0-cm purpuric macules and hemorrhagic vesicles on the bilateral hands and nail beds. Initial blood tests revealed a white blood cell count of 6400 cells (range, 4000 to 11 000/μL; to convert to ×109/L, multiply by 0.001). The patient denied any new medications, any known contacts with or exposures to individuals who were ill, and any history of skin disease. A punch biopsy of the forehead plaque was performed (Figure, B and C). What is your diagnosis?

Two men with toxic shock syndrome presenting with targetoid and spotty skin rashes.

Two previously healthy men who presented with hypotension, constitutional symptoms, and targetoid and discrete spotty erythematous plaques were diagnosed with toxic shock syndrome based on histopathological findings. Specifically, their biopsies revealed necrotic keratinocytes, neutrophils in the epidermis, and neutrophils surrounding dilated superficial vessels. In one case, the diagnosis of toxic shock syndrome was confirmed with rising titers to toxic shock syndrome toxin-1. Both patients recovered with supportive care and clindamycin administration. We suggest that patients with fever, hypotension, constitutional symptoms and rash should be started on clindamycin and have a skin biopsy as part of their initial evaluation. An understanding that toxic shock syndrome can strike anyone has manifold dermatological manifestations and defined histopathological findings is important for its early diagnosis and effective treatment.

Expanding the histologic findings in smallpox-related post-vaccinial non-viral folliculitis.

Post‐vaccinial non‐viral folliculitis has been recognized in the past decade as a new adverse cutaneous reaction to smallpox vaccination. Contrary to more serious smallpox vaccine reactions, post‐vaccinial non‐viral folliculitis has a benign course and resolves spontaneously within approximately 7 days. We describe additional histopathologic findings associated with post‐vaccinial non‐viral folliculitis, which has only been described once previously. New findings include the presence of a neutrophilic or lymphohistiocytic infiltrate that is concentrated around the hair follicles. We compare our findings to the follicular nature of varicella and herpes zoster infections, generating the hypothesis of deposition of vaccinia protein within folliculosebaceous units as a potential pathophysiologic mechanism behind post‐vaccinial non‐viral folliculitis.

Eschar Formation from Testosterone Patch

A 78-year-old man presented for his yearly skin exam and was noted to have an oval-shaped, green-black eschar on his midback. A pink, atrophic scar was located nearby, in addition to a medicated patch of similar size.