A case illustrating successful eradication of recurrent, aggressive basal cell carcinoma located in a scar with vismodegib.

Vismodegib is a small molecule inhibitor of the Hedgehog signaling pathway that has shown efficacy in the control of locally advanced or metastatic basal cell carcinoma, although proof of its effectiveness in the elimination of aggressive tumors is lacking. We report a case and provide complete histological evidence of a 69-year-old gentleman who presented with a recurrent, infiltrative, and sclerosing (morpheiform) basal cell carcinoma on his left upper lip that was entirely eradicated with a three-month course of vismodegib 150 mg daily. Complete histologic clearance of a tumor in a recurrent, infiltrative, and sclerosing basal cell carcinoma with vismodegib is uncommon.

The residency interview is still paramount: results of a retrospective cohort study on concordance of dermatology residency applicant evaluators and influence of the applicant interview.

Application to dermatology residency is a highly competitive process. Although factors associated with successfully matching have been studied, less is known regarding the ability of admissions committees to screen applicants in a uniform manner or the importance of the interview in ranking applicants. Our goal was to retrospectively measure our admission committee evaluators' concordance regarding residency application credentials and interview performance, and ultimately the effects on final applicant ranking.

Disseminated cutaneous sporotrichosis presenting as a necrotic facial mass: Case and review.

Sporotrichosis is a subcutaneous mycotic infection caused by Sporothrix schenckii, a group of common saprophytes of soil, plants, and organic debris. Disseminated forms may be seen in the setting of immunosuppression and are typically treated initially with intravenous lipidized amphotericin B. We report an unusual case of a 65-year-old woman who developed disseminated cutaneous sporotrichosis with extensive facial involvement in the absence of a known primary inoculation. Her cutaneous lesions completely resolved after treatment with intravenous posaconazole without amphotericin B.

Daylight Photodynamic Therapy: What is Known and What is Yet to be Determined.

BACKGROUND: Photodynamic therapy (PDT) has been used extensively to treat actinic keratoses (AKs) and less so nonmelanoma skin cancers (NMSC). Conventional in-office treatment is limited by intensive time requirements and patient discomfort. A new trend toward the use of daylight as a light source either clinically monitored or self-supervised is gaining acceptance. OBJECTIVE: To assess the current published data on daylight photodynamic therapy (dPDT) and identify knowledge gaps. METHODS AND MATERIALS: A systematic search of the PubMed archives using the terms daylight PDT, daylight-PDT, daylight photodynamic therapy, and ambient light and photodynamic therapy was conducted on May 18, 2015. No restrictions were used for the search string. RESULTS: Seventeen published works were identified on the use of dPDT; 8 randomized studies, 4 prospective cohort studies, 1 case series, 1 case report, and 3 retrospective studies. Complete response rates for treatment of AKs from randomized trials range from 46% to 89.2%. CONCLUSION: Daylight PDT has been demonstrated to have high efficacy with results similar to conventional PDT for the treatment of AKs. Initial reports regarding treatment of NMSC indicate recurrence rates much higher than other accepted therapies. Pain associated with treatment seems to be significantly less than for conventional PDT.

100% Complete response rate in patients with cutaneous metastatic melanoma treated with intralesional interleukin (IL)-2, imiquimod, and topical retinoid combination therapy: results of a case series.

BACKGROUND: Patients with cutaneous melanoma metastases have experienced excellent responses to intralesional interleukin (IL)-2. This has led to its recent inclusion into the US National Comprehensive Cancer Network guidelines for management of cutaneous melanoma metastases. Despite this, intralesional IL-2 has not been highlighted in the US literature nor have US physicians adopted it. OBJECTIVE: We sought to evaluate the effectiveness of intralesional IL-2 combined with topical imiquimod and retinoid for treatment of cutaneous metastatic melanoma. METHODS: A retrospective case series of 11 patients with cutaneous metastatic melanoma were treated with intralesional IL-2 combined with topical imiquimod and retinoid. RESULTS: A 100% complete local response rate with long-term follow-up (average of 24 months) was seen in all 11 patients treated with this proposed regimen. Biopsy specimens of treated sites confirmed absence of malignant cells. The most common treatment-related adverse event was rigors. LIMITATIONS: Small number of patients, retrospective review of charts, and lack of a comparison group were limitations. CONCLUSION: Intralesional IL-2 administered concomitantly with topical imiquimod and a retinoid cream is a promising therapeutic option for managing cutaneous melanoma metastases. The regimen was well tolerated and should be considered as a reasonable alternative to surgical excision.

Set-back versus buried vertical mattress suturing: results of a randomized blinded trial.

BACKGROUND: The set-back suture, an absorbable dermal suturing technique, purportedly improves wound eversion and cosmetic outcomes. OBJECTIVE: We sought to conduct a split-wound, prospective, randomized study to compare the cosmetic outcome and wound eversion achieved with the set-back suture and the buried vertical mattress suture (BVMS). METHODS: A total of 46 surgical elliptical wounds were randomized to subcuticular closure with the set-back suture on half and the BVMS on the other. Maximum eversion height and width were measured immediately postoperatively. At 3 months, 2 blinded observers evaluated each scar using a 7-point Likert physician global scar assessment scale. Subjects and observers also completed the validated Patient and Observer Scar Assessment Scale, where a score of 6 represents normal-appearing skin and 60 represents worst imaginable scar. RESULTS: In all, 42 subjects completed the study. The set-back suture provided statistically significant wound eversion. On the Likert scale, observers rated the set-back suture side 1 point better than the BVMS side. Both patient and observer total Patient and Observer Scar Assessment Scale scores were significantly lower for the set-back suture side (subject mean 13.0 ± 8.7 vs 16.2 ± 12.0 [P = .039]; observer mean 24.5 ± 10.4 vs 27.7 ± 13.6 [P = .028], respectively). LIMITATIONS: Single institution experience and relatively short follow-up are limitations. CONCLUSION: The set-back suture provides superior wound eversion and better cosmetic outcomes than the BVMS.

Effective strategies for the management of pyoderma gangrenosum: a comprehensive review.

Pyoderma gangrenosum (PG) is an inflammatory disease characterized by painful skin ulcerations with undermined and erythematous borders. The etiology of PG is not well understood, but it is generally considered to be an aberrant immune response characterized by a dermal neutrophilc infiltrate. Given the existence of only a few PG clinical trials, treatment options are largely based upon anecdotal data and small case studies. In addition to classic immunosuppressive medications, PG has been reported to respond well to the anti-TNF agents, infliximab, etanercept, adalimumab. Newer biologics such as ustekinumab (anti-IL-23), ixekizumab (anti-IL-17) and brodalumab (anti-IL-17R) are promising given the effect of IL-17 on neutrophil migration. However, the effectiveness of these newer agents remains to be rigorously evaluated. Multi-drug regimens have not been well described in the literature but are an excellent alternative for patients with refractory disease. Herein, we provide a comprehensive review of the pathophysiology of PG and of the different treatments available for managing PG patients, including the theoretical benefit of initiating multidrug regimens. We also provide one possible treatment algorithm for patients with refractory disease and give examples of refractory PG cases successfully treated with multidrug regimens.

Metastatic melanoma - a review of current and future treatment options.

Despite advances in treatment and surveillance, melanoma continues to claim approximately 9,000 lives in the US annually (SEER 2013). The National Comprehensive Cancer Network currently recommends ipilumumab, vemurafenib, dabrafenib, and high-dose IL-2 as first line agents for Stage IV melanoma. Little data exists to guide management of cutaneous and subcutaneous metastases despite the fact that they are relatively common. Existing options include intralesional Bacillus Calmette-Guérin, isolated limb perfusion/infusion, interferon-α, topical imiquimod, cryotherapy, radiation therapy, interferon therapy, and intratumoral interleukin-2 injections. Newly emerging treatments include the anti-programmed cell death 1 receptor agents (nivolumab and pembrolizumab), anti-programmed death-ligand 1 agents, and oncolytic vaccines (talimogene laherparepevec). Available treatments for select sites include adoptive T cell therapies and dendritic cell vaccines. In addition to reviewing the above agents and their mechanisms of action, this review will also focus on combination therapy as these strategies have shown promising results in clinical trials for metastatic melanoma treatment.

Mycobacterium chelonae infection presenting as recurrent cutaneous and subcutaneous nodules--a presentation previously diagnosed as Weber Christian disease.

Although the dermatologic community rarely uses "Weber-Christian Disease" as a diagnosis, it still appears in the internal medicine literature. Herein we present a patient with recurrent cutaneous and subcutaneous nodules who was initially treated with aggressive immunosupression for a presumptive diagnosis of Weber-Christian Disease. After more than a decade the patient was diagnosed with cutaneous Mycobacterium chelonea. This case is an excellent example of the difficulty in diagnosing mycobacterial infections and underscores the importance of having a high suspicion for infectious etiologies for unresponsive cutaneous eruptions in patients on immunosuppressive medications.

A pilot study demonstrating a non-invasive method for the measurement of protein turnover in skin disorders: application to psoriasis.

BACKGROUND: Previous studies of epidermal kinetics in psoriasis have relied on invasive biopsy procedures or the use of radioactive labels. We previously developed a non-invasive method for measuring keratin synthesis in human skin using deuterated water labeling, serial collection of tape strips and measurement of deuterium enrichment in protein by mass spectrometry. This powerful method can be applied to measure other skin proteins and lipids collected by tape stripping. Here, for the first time, we apply this technique to investigate the epidermal kinetics of psoriasis, the first step in defining a kinetic profile for normal skin versus activated or quiescent psoriatic skin. METHODS: Psoriatic subjects were given (2)H2O orally as twice-daily doses for 16-38 days. Affected and unaffected skin was sampled by tape stripping and washing (modified Pachtman method). Proteins were isolated from the tape strips by a method that enriches for keratin. Turnover times were determined by gas chromatography/mass spectrometry. Kinetic data were compared to transepidermal water loss (TEWL). RESULTS: Deuterium-labeled protein from lesional psoriatic skin appeared at the skin surface within 3-8 days of label administration, whereas labeled protein from non-lesional skin requires 10-20 days to appear. Psoriatic skin had similar rate of growth despite varying anatomic location. Proteins recovered from tape strips were identified by nanoscale liquid chromatography/tandem mass spectrometry. Isolated peptides were >98% from keratin in uninvolved skin and >72% keratin in psoriatic skin. Revealing that one-quarter of all newly synthesized proteins in psoriatic skin are antimicrobial defense and other immune-related proteins. TEWL values were greater in lesional than non-lesional skin, suggesting barrier compromise in psoriatic skin despite increased clinical thickness. CONCLUSIONS: This simple, elegant, and non-invasive method for measuring epidermal protein synthesis, which can also be adapted to measure epidermal lipids, provides a metric that may reveal new insights into the mechanisms and dynamic processes underlying psoriasis and may also provide an objective scale for determining response to therapeutic agents in pre-clinical and clinical trials. This opens a pathway to the non-invasive study of kinetics of protein formation in psoriasis or other skin diseases.

Combination therapy with intralesional triamcinolone and oral dapsone for management of palisaded neutrophilic and granulomatous dermatitis.

Palisaded neutrophilic and granulomatous dermatitis (PNGD) is a rare granulomatous disease with limited therapeutic options. Herein we present a patient whose skin lesions recurred after surgery and oral steroids, but responded well to a combination of intralesional triamcinolone and oral dapsone.