Severe de novo pustular psoriasiform immune-related adverse event associated with nivolumab treatment for metastatic esophageal adenocarcinoma.

Breakthrough targeted therapies have produced significant improvements in survival for cancer patients, but have a propensity to cause cutaneous immune-related adverse events (irAEs). Psoriasiform irAEs, representing about 4% of dermatologic toxicities associated with immune checkpoint inhibitor (ICI) therapy, are usually mild, occur in older patients and present as an exacerbation of existing psoriasis after several doses of ICI therapy. We report a case of a 58-year-old woman with metastatic esophageal adenocarcinoma and no prior history of psoriasis who developed a pustular psoriasiform irAE, beginning 3 days after initiation of nivolumab and progressing to confluent erythroderma with pustules over 2 weeks despite topical steroid use. She had concurrent acrodermatitis enteropathica, clinically diagnosed and confirmed with a low serum zinc level, that improved with supplementation. Her psoriasiform irAE was refractory to systemic steroids and acitretin, prompting discontinuation of nivolumab and treatment with ustekinumab and concomitant slow taper of acitretin and prednisone. Pustular psoriasiform irAE is a rare but severe dermatologic toxicity resulting from ICI therapy. Given the diverse morphologic types of cutaneous irAEs that can occur during ICI therapy, a clinical and histopathologic examination of dermatologic toxicities is critical to identify patients who may benefit from biologic therapy.

Treatment of keloids with a single dose of low-energy superficial X-ray radiation to prevent recurrence after surgical excision: An in vitro and in vivo study.

BACKGROUND: Although keloids have been empirically treated with steroids and radiation, evidence-based radiation parameters for keloid therapy are lacking. OBJECTIVE: To determine evidence-based radiation parameters for blocking keloid fibroblast proliferation in vitro and apply them to patients. METHODS: The effects of various radiation parameters and steroids on cell proliferation, cell death, and collagen production in keloid explants and fibroblasts were evaluated with standard assays. Effective radiation parameters were then tested on patients. RESULTS: No differences were observed between the effects of 50 and 320 kV radiation or between single and fractionated radiation doses on keloid fibroblasts. A 3 Gy, 50 kV dose inhibited keloid fibroblast proliferation in culture, whereas 9 Gy completely blocked their outgrowth from explants by inducing multiple cell death pathways and reducing collagen levels. Thirteen of 14 keloids treated with a single 8 Gy, 50 kV dose of radiation did not recur, although 4 patients with 6 keloids were lost to follow-up. LIMITATIONS: Seventy-five percent of patients received steroids for pruritus, whereas approximately 25% of patients were lost to follow-up. CONCLUSIONS: A single 8 Gy dose of superficial 50 kV radiation delivered an average of 34 days after keloid excision maybe sufficient to minimize recurrence, including in individuals resistant to steroids. Higher radiation energies, doses, or fractions may be unnecessary for keloid therapy.

Novel Combination of a 650-Microsecond Neodymium-doped Yttrium Aluminium Garnet 1,064-nm Laser and Cysteamine Cream for the Treatment of Melasma: A Case Study.

Melasma is a common pigmentation disorder with few satisfactory treatment options. The hyperpigmentation has both an epidermal and dermal component. To date, combination therapies have been observed to yield greater improvements in melasma compared to monotherapies. Cysteamine has been tested and shown to improve epidermal melasma. In this case series, we examined the efficacy of nightly applications of cysteamine cream, washed off after 15 minutes, with monthly in-office laser treatment sessions using a 650-microsecond neodymium-doped yttrium aluminium garnet 1,064-nm laser. The patients all reported satisfaction with the results of this combination therapy. None of the patients experienced irritation with the product nor did they experience discomfort/downtime with the laser sessions. Evaluation of the patients two months after the treatment indicated persisting effects. Our small case series suggests high levels of satisfaction can be achieved using this combined topical and laser approach.

Case Report: Triple Combination Therapy for Recalcitrant Perineal Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a destructive ulcerative process, which is usually idiopathic or associated with underlying systemic disease. Its pathogenesis remains unknown. A 30-year-old male with a history of Crohn's disease presented with an advanced perineal and inguinal ulcer consistent with pyoderma gangrenosum, which only partially responded to oral and intralesional corticosteroids and adalimumab 80mg biweekly. The patient was started on adjunct combination cyclosporine and thalidomide, which resulted in prompt relief and profound healing. Treatment of pyoderma gangrenosum is often challenging with no standardized treatment protocols. Combination therapy should be considered in patients with refractory disease, especially with failure of monotherapy. J Drugs Dermatol. 2019;18(3):307-310.

Integrating the Integumentary System with the Arts: A Review of Dermatologic Findings in Artwork.

The objectives of this review are to demonstrate that portraits, in their visual reflections of subjects faces and expressions, offer significant representations relevant to the field of dermatology and bring attention to an underappreciated aesthetic of dermatological conditions. The review comprises paintings that purposefully or inadvertently depict dermatological conditions. The findings were substantiated by searching PubMed using the keywords art, painting, and dermatology, as well as combinations of these terms. The "Notable Notes" section of JAMA Dermatology proved especially useful. The review is subdivided by disease category, including portraits that display infectious diseases, neoplastic conditions, genetic dermatoses, rosacea and/or acne, and autoimmune disorders. The breadth of examples of dermatology represented in art suggest that portraits might serve as an unintentional atlas of dermatological conditions. By implication, it seems that the arts might be more interconnected to the sciences than traditionally acknowledged.

Phacomatosis Pigmentokeratotica: A Mosaic RASopathy with Malignant Potential.

Phacomatosis pigmentokeratotica (PPK) is a rare epidermal nevus syndrome characterized by the co-occurrence of a nevus sebaceous arranged along the lines of Blaschko with a speckled lentiginous nevus (SLN). We report a novel KRAS mutation in a patient with a large nevus sebaceous and an SLN who subsequently developed a vaginal botryoid rhabdomyosarcoma, an association not previously reported in the literature. This case expands our knowledge of the genetic basis for phacomatosis, in which mutations in HRAS have been previously described, although this report provides evidence that activating mutations in KRAS or HRAS may cause PPK. This report confirms that PPK is a mosaic RASopathy with malignant potential and raises the question of whether screening for other RAS-associated malignancies should be performed for all children with PPK.