Questioning the specificity and sensitivity of ELISA for bullous pemphigoid diagnosis.

The reported sensitivity and specificity of enzyme-linked immunosorbent assay (ELISA) for bullous pemphigoid (BP) diagnosis is approximately 87% and 98%, respectively. These statistics suggest that ELISA is a reliable diagnostic test; therefore, the use of ELISA for BP diagnosis has increased. We report the case of a man who was diagnosed with BP and was treated for 3 years based on a positive ELISA for IgG against BP180. After reevaluation, his revised diagnosis was not consistent with BP based on clinical presentation, histopathology, and direct immunofluorescence (DIF). Reviewing reports of ELISA for BP diagnosis in the literature revealed several issues including dissimilar diagnostic procedures and patient populations, multiple reports of positive ELISA in patients without BP, and lack of explanation for these false-positives. This case report and review of the literature is a cautionary tale regarding the use of ELISA as an independently reliable test for BP diagnosis.

A Souvenir From France: Acrodermatitis Chronica Atrophicans Presenting in the United States.

A 70-year-old man was referred by his rheumatologist to our dermatology clinic for evaluation of dermatitis on his right arm that appeared 3 months earlier. The skin lesion was asymptomatic and the patient denied current systemic symptoms, including fever, chills, and joint pain; however, 10 months prior to this presentation he experienced arthritis in the left knee. At that time, Borrelia serology revealed positive IgG (6.07; <0.8 negative, 0.8 to 0.99 borderline, ≥1 positive) and negative IgM titers. The patient had not received treatment for Lyme disease in the past. He was referred to rheumatology for evaluation of possible Lyme disease but did not follow up until 10 months later. The arthritis has since resolved. He travels frequently to France and recalls multiple tick bites during these trips.

Diet in dermatology: Part I. Atopic dermatitis, acne, and nonmelanoma skin cancer.

Patients commonly inquire about dietary modifications as a means to prevent or manage skin disease. Answering these questions is often challenging, given the vast and conflicting evidence that exists on this topic. This 2-part continuing medical education article summarizes the evidence to date to enable physicians to answer patients' questions in an evidence-based manner. Part I includes atopic dermatitis, acne, and nonmelanoma skin cancer. The role of dietary supplementation, dietary exclusion, food allergy, maternal diet, and breastfeeding in the development and/or prevention of atopic dermatitis is summarized. The dermatoendocrinologic mechanism for the effects of glycemic index/glycemic load and milk on acne is described, as well as related clinical evidence for dietary modifications. Finally, evidence and recommendations for restriction or supplementation of dietary factors in the prevention of nonmelanoma skin cancer, including fat, vitamins A, C, D, and E, and selenium, are reported.

Diet in dermatology: Part II. Melanoma, chronic urticaria, and psoriasis.

The roles of dietary factors in aggravating, preventing, or treating skin diseases are common questions encountered in dermatology practice. Part II of this two-part series reviews dietary modifications that can potentially be utilized in the management of melanoma, chronic urticaria, and psoriasis patients. Specifically, we examine the effect of alcohol consumption and supplementation with vitamins D and E, polyunsaturated fatty acids, selenium, green tea, resveratrol, and lycopene on melanoma risk. The relationships between chronic urticaria symptoms and dietary pseudoallergens, gluten, and vitamin D are analyzed. We explore weight loss, reduced alcohol consumption, and gluten avoidance as means of reducing psoriasis-associated morbidity, as well as the possible utility of supplementation with polyunsaturated fatty acids, folic acid, vitamin D, and antioxidants. With proper knowledge of the role of diet in these cutaneous disease processes, dermatologists can better answer patient inquiries and consider implementation of dietary modifications as adjuncts to other treatments and preventative measures.

Tungiasis in Haiti: a case series of 383 patients.

BACKGROUND: Tungiasis is endemic in poverty-stricken communities of South and Central America, Africa, Asia, and the Caribbean. This ectoparasitosis, caused by the female sand flea Tunga penetrans, is associated with considerable longterm morbidity in severely affected patients, including toe deformation and limited mobility. In Haiti, tungiasis is poorly documented but is known to occur. This study is the first formal investigation of tungiasis in Haiti. METHODS: A total of 383 patients in four regions (Belle Fontaine, Vallue, Savanette, Cerca Carvajal) were examined and interviewed to determine disease prevalence, demographics and clinical presentation, and tungiasis-related behaviors. RESULTS: Prevalences of tungiasis ranged from 10.6 to 81.8% across the four regions. The overall prevalence of tungiasis in the patients examined was 31.1%. Of the affected patients, 63% were male and 37% were female, 37% were aged 0-10 years, and 100% reported pain and pruritus. Lesions occurred on the feet in 93.3% and on the hands in 22.7% of affected patients. The most common complications observed were chronic inflammation (54.2%) and hyperkeratosis (48.2%). CONCLUSIONS: This study establishes tungiasis as endemic in four regions of Haiti and reveals disease characteristics similar to those reported previously, suggesting that there are common factors underlying this disease in various regions, which are likely to be poverty-related. These findings emphasize the need to acknowledge tungiasis as a clinically relevant public health issue in order to decrease the frequency of tungiasis-related morbidity in endemic areas.

Outcomes of biopsies and excisions of dysplastic acral nevi: a study of 187 lesions.

BACKGROUND: Despite their frequency in clinical practice, controversy exists regarding the significance and management of dysplastic nevi (DN). Although the perception of DN as precursors to melanoma is questionable, excisions of biopsy-proven DN are commonplace in clinical practice. The management of dysplastic acral nevi is of interest given the challenge of surgery at acral sites. OBJECTIVE: To determine the outcomes of biopsies of clinically atypical acral nevi and excisions of histologically dysplastic acral nevi (HDN). MATERIALS AND METHODS: Retrospective review of consecutive patients at a private dermatology practice who had a biopsy of an atypical acral nevus from December 2004 to July 2012. RESULTS: One hundred eighty-seven atypical acral nevi were biopsied from 168 patients (77 (41%) HDN, 108 (58%) common nevi). Based on initial histology, 30 (39%) HDN were recommended for excision and eight (10%) for clinical observation. Twenty-seven of the 77 HDN were excised; 23 (85%) revealed scar only, and four (15%) revealed residual DN not involving the margin. CONCLUSION: Routine excision of biopsy-proven dysplastic acral nevi may not be necessary.

From mole to scar: the unintended consequence of treatment with an over-the-counter mole removal cream.

A 26-year-old man presented with a scar at the site of a pigmented lesion treated with DermaTend (Solace Interntational, Inc., Reno, NV), an over-the-counter mole removal cream. According to the patient, the pigmented lesion had been present since childhood, was asymptomatic, and had not changed in appearance. It remained cosmetically displeasing to him. In an effort to remove the lesion, he had applied DermaTend on a daily basis for several weeks, at which point he noticed a scar at the site of treatment.