Susan Burgin

Chemotherapeutic agents and the skin: An update

UNLABELLED Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions. LEARNING OBJECTIVES At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.

Autoantibodies in black South Africans with systemic lupus erythematosus: spectrum and clinical associations.

SummaryThe clinical features and autoantibody profile of 111 black South Africans (103 females and 8 males) with systemic lupus erythematosus were retrospectively analysed. The mean age of the patients was 35.1 years and mean duration of disease 3.5 years. The commonest clinical and laboratory features noted were arthritis (62.2%), hypocomplementaemia (61.2%), haematological abnormalities (60.5%) and malar rash (55%). The serological abnormalities included antinuclear antibodies (98.2%), anti-dsDNA (66.2%), anti-Sm (44.2%), anti-RNP (65.5%), anti-Ro (60.5%), anti-La (28.4%) and rheumatoid factor (10.1%). Positive clinicoserological associations observed included: combination of anti-dsDNA antibodies and low C4 levels with renal disease; anti-dsDNA antibodies with cutaneous vasculitis; anti-Sm antibodies with psychosis; anti-RNP antibodies with Raynauds phenomenon; anti-Ro antibodies with renal disease, psychosis and malar rash. Anti-La antibodies showed a weak negative association with serositis and Raynauds phenomenon. Most of these clinical correlates are consistent with past studies. The high frequency of anti-Sm and anti-RNP antibodies is similar to the observations in African-Americans and Afro-Caribbeans.

Granulomatous pigmented purpura: report of a case and review of the literature

The pigmented purpuric dermatoses (PPD) are a group of diseases characterized by petechiae and bronze discoloration of the skin on the lower extremities. Histopathologically, extravasation of erythrocytes with hemosiderin deposition, a perivascular lymphocytic infiltrate centered on the superficial capillaries and endothelial cell swelling are seen. The granulomatous variant of PPD (GPPD) was described in 1996 and only 10 cases have been reported since in the literature, almost exclusively in patients of East Asian descent only involving the extremities. We present a case of GPPD in a Caucasian, North American Ashkenazi Jewish woman involving the thighs, back, forearms and wrists with concomitant non‐granulomatous PPD of the shins. She presented with an asymptomatic, spreading, cayenne pepper‐like rash. This rash intermittently involved the lower extremities and back for 15 years, but now involves the thighs with accompanying pink papules on the back, wrists and forearms. Histopathology of the thigh and back lesions revealed superficial lichenoid granulomatous dermatitis with palisading lymphocytes and focal interface changes. Extravasated erythrocytes were seen, but vasculitis was absent. No lymphocytic atypicality was noted and T‐cell gene rearrangement studies were non‐clonal. This is the second reported case of GPPD in a non‐Asian patient and the first case involving sites other than the extremities.

Case records of the Massachusetts General Hospital. Case 18-2014. A 32-Year-old man with a rash, myalgia, and weakness.

Dr. Eli Miloslavsky (Medicine): A 32-year-old man was admitted to this hospital because of a rash, muscle pain, weakness, and respiratory failure. The patient had been well until 10 weeks before admission, when a violaceous rash developed involving the eyelids, elbows, metacarpophalangeal and proximal interphalangeal joints, and knees. One week later, intense generalized muscle pain and weakness developed, including difficulty walking, arising from a squat, and climbing stairs. Two weeks later, examination at another hospital revealed a heliotrope rash (a red-to-purple rash on the eyelids), periungual edema, erythematous papules on the fingertips, and moderate-to-severe weakness of the deltoids, triceps, hip flexors, hamstrings, and quadriceps bilaterally. Muscle bulk and tone, deeptendon reflexes, and the sensory examination were normal. Electrodiagnostic studies of muscle and nerve reportedly showed evidence of a chronic proximal myopathy with inflammatory features. Prednisone, 80 mg daily, was administered, with transient improvement in weakness and a reported decrease in the serum creatine kinase level, from 6700 U per liter to 4200 U per liter. Twenty-six days before admission, the administration of azathioprine, 150 mg per day, was begun because of the patient’s progressive weakness (including difficulty raising his arms) and tenderness on deep palpation of the proximal limbs. Two days later, tests of coagulation and the blood level of total bilirubin were normal; other test results are shown in Table 1. Azathioprine was stopped after 2 days because of a rise in the creatine kinase level, and the patient was admitted to the other hospital. Computed tomography (CT) of the chest and abdomen revealed a small left pleural effusion and anasarca. Magnetic resonance imaging (MRI) performed after the administration of gadolinium reportedly revealed enhancement and edema throughout the major muscle groups of the right thigh. Pathological examination of a biopsy specimen of skeletal muscle reportedly revealed mildly increased variation in fiber size and occasional degenerating fibers, myonecrosis, vascular injury, and fibrosis. Rituximab and a 5-day course of intravenous immunoglobulin were administered. Anemia and hypertension reportedly developed. Red cells (6 units) were transfused and antihypertensive agents were administered. Pathological examination of a biopsy specimen of the bone marrow showed normal trilineage hematopoiesis and no malignant cells. Fever developed, and a possible pulmonary infilCase 18-2014: A 32-Year-Old Man with a Rash, Myalgia, and Weakness

Case 18-2014

Dr. Eli Miloslavsky (Medicine): A 32-year-old man was admitted to this hospital because of a rash, muscle pain, weakness, and respiratory failure. The patient had been well until 10 weeks before admission, when a violaceous rash developed involving the eyelids, elbows, metacarpophalangeal and proximal interphalangeal joints, and knees. One week later, intense generalized muscle pain and weakness developed, including difficulty walking, arising from a squat, and climbing stairs. Two weeks later, examination at another hospital revealed a heliotrope rash (a red-to-purple rash on the eyelids), periungual edema, erythematous papules on the fingertips, and moderate-to-severe weakness of the deltoids, triceps, hip flexors, hamstrings, and quadriceps bilaterally. Muscle bulk and tone, deeptendon reflexes, and the sensory examination were normal. Electrodiagnostic studies of muscle and nerve reportedly showed evidence of a chronic proximal myopathy with inflammatory features. Prednisone, 80 mg daily, was administered, with transient improvement in weakness and a reported decrease in the serum creatine kinase level, from 6700 U per liter to 4200 U per liter. Twenty-six days before admission, the administration of azathioprine, 150 mg per day, was begun because of the patient’s progressive weakness (including difficulty raising his arms) and tenderness on deep palpation of the proximal limbs. Two days later, tests of coagulation and the blood level of total bilirubin were normal; other test results are shown in Table 1. Azathioprine was stopped after 2 days because of a rise in the creatine kinase level, and the patient was admitted to the other hospital. Computed tomography (CT) of the chest and abdomen revealed a small left pleural effusion and anasarca. Magnetic resonance imaging (MRI) performed after the administration of gadolinium reportedly revealed enhancement and edema throughout the major muscle groups of the right thigh. Pathological examination of a biopsy specimen of skeletal muscle reportedly revealed mildly increased variation in fiber size and occasional degenerating fibers, myonecrosis, vascular injury, and fibrosis. Rituximab and a 5-day course of intravenous immunoglobulin were administered. Anemia and hypertension reportedly developed. Red cells (6 units) were transfused and antihypertensive agents were administered. Pathological examination of a biopsy specimen of the bone marrow showed normal trilineage hematopoiesis and no malignant cells. Fever developed, and a possible pulmonary infilCase 18-2014: A 32-Year-Old Man with a Rash, Myalgia, and Weakness

Adverse Effects of Q‐Switched Laser Treatment of Tattoos

A 26-year-old woman presented for consultation regarding laser removal of a professional tattoo. There had been no prior attempts at tattoo removal. Physical examination revealed a black tattoo in the form of a dragon on the mid-lower back (Figure 1). Initially, the patient underwent a test treatment on the lower portion of the tattoo. The Q-switched ruby laser (QSRL) was used at a fluence of 4.0 J/cm and a spot size of 6.5 mm.

Teaching & Learning Tips 4: Motivation and emotion in learning

Challenge: Trainees’ motivational and emotional states can influence their learning and career decisions, but historically these “affective” learning factors have received little attention in medical education. In this “Tips” piece, we outline strategies to positively influence trainees’ intrinsic motivation and emotion toward their training to ultimately enhance their overall learning experience.

Teaching & Learning Tips 5: Making lectures more “active”

Challenge: Although lecturing is an efficient method for the dissemination of information, it has long been criticized for learner passivity and diminished knowledge retention. Active learning strategies to engage the audience in the learning process can facilitate a bidirectional flow of ideas and content between teacher and students during a lecture to keep learners engaged and participating.

Teaching & Learning Tips 2: Cognitive load theory

Challenge: Dermatology trainees include medical students, residents, and fellows. Variability in level of experience and background knowledge can make clinical teaching challenging. Research also shows novices have different ways of thinking than experts, which must be acknowledged in the preceptor‐trainee interaction for optimal teaching and learning to occur. Herein we explore how “cognitive load” varies with learner level and how reducing cognitive load can enhance learning, especially for novice learners.

A cross-sectional survey on the attitudes, perceptions, and motivations of patients who volunteer to teach dermatology to medical students.

While areas of blood flow are usually unchanged after Wood lamp irradiation, cutaneous blood flow itself was also reported associated with activity of vitiligo lesions. Furthermore, unrecognized mechanisms must have been related considering the locations of linear streaks exactly along the superficial leg vein. From the rarity of this reaction, we postulate that this may be an idiosyncratic reaction in a genetically susceptible patient, while future studies are required. For previous cases with triamcinolone injections, hypopigmentation generally began to resolve without further treatment, several months after discontinuation of the steroid. In this case, hypopigmentation has persisted for more than 7 months even after cessation of application. Permanent hypopigmentation is an important cosmetic issue, and in this case, just application of mid potent topical steroid cream for 2 weeks caused broad linear hypopigmentation extending from the original site. This case is presented to draw the physicians’ attention to a new possible side effect observed during patients’ application of corticosteroids – one of the most widely prescribed medications in dermatology.