A Curious Case of Medium-Vessel Vasculitis.

Vasculitis, or the inflammation of vessels due to primary or secondary causes, may arise from numerous etiologies, often leading to diagnostic uncertainty. Delayed treatment due to diagnostic or etiologic uncertainty presents a significant clinical risk, with consequences including organ failure and mortality. We describe a case of a 58-year-old male with a history including ankylosing spondylitis who presented with painful ulcers involving the bilateral lower extremities following a trip to the southern Texas border. Histopathology revealed medium-vessel vasculitis; however, the search for a likely etiology in the setting of a unique combination of potential vasculitis precipitants, including glochid inoculation, a spider bite, prior IL-17 inhibitor use, and inflammatory bowel disease, contributed to treatment delay and disease progression. Although the patient was ultimately successfully treated with systemic corticosteroids, this case highlights the importance of initiating prompt therapy once vasculitis is recognized to prevent disease progression, even if lacking an identified etiology.

Advances in Technology for Melanoma Diagnosis and Prognosis: An Expert Consensus Panel.

BACKGROUND: Cutaneous melanoma (CM) is associated with a higher mortality rate than most other skin cancers. The purpose of this expert consensus panel was to review the published literature on new technological advancements for the diagnosis and prognosis for CM and provide updated guidance on their usage. METHODS: A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed for English-language original research articles on the topics of non-invasive diagnostic and prognostic testing for CM, including gene expression profiling (GEP) and electrical impedance spectroscopy (EIS). A panel of 10 dermatologists with significant expertise in the treatment of CM gathered to review the articles and create consensus statements. A modified Delphi process was used to approve each statement and a strength of recommendation was assigned using widely recognized Strength of Recommendation Taxonomy criteria. RESULTS: The literature search produced 200 articles that met the criteria. A screening of the studies resulted in 19 articles. These were distributed to all panelists for review prior to a roundtable discussion. The panel unanimously voted to adopt 7 consensus statements and recommendations, 5 of which were given a strength of "A", 1 of which was given a strength of "B," and 1 of which was given a strength of "C". CONCLUSION: The 2-GEP test and EIS can aid in the precise diagnosis of clinically indeterminate lesions and the 23-GEP test can be used when histopathology is equivocal. The 31-GEP test can enhance prognostic assessment beyond AJCC8 staging and improve clinical decision-making. J Drugs Dermatol. 2024;23(9):774-781. doi:10.36849/JDD.8365R1.

Herpes Vegetans in a Patient With Acquired Immunodeficiency Syndrome (AIDS) in the Setting of Immune Reconstitution Inflammatory Syndrome.

Herpes simplex virus (HSV) infections classically present as a vesicular eruption on an erythematous base; however, viral infections may present much differently in the setting of immune deficiency. Herpes vegetans is an atypical presentation of HSV that occurs in immunocompromised patients, typically those with human immunodeficiency virus infection and acquired immunodeficiency syndrome (AIDS). Herpes vegetans is characterized by hyperkeratotic, exophytic, and, sometimes, ulcerated nodules, often with a chronic and persistent course. Herein, we present an interesting example of biopsy-confirmed anogenital herpes vegetans in a 61-year-old male with AIDS in the setting of immune reconstitution inflammatory syndrome, an association that is less frequently described. This case serves as an important reminder to consider atypical presentations of infectious disease when examining immunocompromised patients, as prompt diagnosis and treatment are essential in this population.

Two Cases of Pigmented Basal Cell Carcinoma in African American Patients.

Basal cell carcinoma (BCC) is the most common cutaneous malignancy, comprising approximately 80% of non-melanoma skin cancers. There are numerous subtypes, including pigmented basal cell carcinoma (pBCC), a rare clinical and histological variant. Skin cancers in African American patients, although rare, still do occur. BCC is an uncommon neoplasm in this population, but when it does occur, pigmentation is present in more than 50% of tumors compared with only 5% to 6% of BCCs in Caucasians. This report presents two cases of histologically verified pBCC in African American patients from dermatology clinics at the Veterans Affairs Hospital located in the Texas Medical Center. With the population of the United States growing more diverse, these cases emphasize the importance of recognizing the nuanced morphology of BCC in the skin of color compared to lighter-skinned counterparts. This is especially necessary, as early detection and prompt management are key to combating the disproportionately high morbidity and mortality related to skin cancers affecting patients of color.

Bacillary Angiomatosis in a Patient With HIV and Disseminated Mycobacterium avium Complex Infection.

Bartonella is a genus of arthropod-borne bacterial pathogens that typically cause persistent infections of erythrocytes and endothelial cells in mammalian hosts. The species that primarily infect humans are Bartonella henselae and Bartonella quintana. Depending on immune status, the clinical presentation of B. henselae may differ, manifesting as cat-scratch disease in immunocompetent individuals or bacillary angiomatosis (BA) and peliosis in immunocompromised patients. The cutaneous manifestations of BA are typically characterized by occasionally painful, angiomatous papules and nodules, often with a chronic, persistent course. Herein, we present a case of biopsy-confirmed B. henselae infection in a 32-year-old HIV-positive female with acquired immunodeficiency syndrome in the setting of disseminated Mycobacterium avium complex infection, an association that has been less frequently described. This case serves as an important reminder to consider uncommon opportunistic infectious etiologies when examining immunocompromised patients, as prompt diagnosis and treatment are essential in this patient population.

Dermatologic Fungal Neglected Tropical Diseases-Part I. Epidemiology and Clinical Features.

In this part 1 of a 2-part continuing medical education series, the epidemiology, clinical features, and diagnostic methods for fungal skin neglected tropical diseases (NTDs), which include eumycetoma, chromoblastomycosis, paracoccidioidomycosis, sporotrichosis, emergomycosis, talaromycosis, and lobomycosis, are reviewed. These infections, several of which are officially designated as NTDs by the World Health Organization (WHO), cause substantial morbidity and stigma worldwide and are receiving increased attention due to the potential for climate change-related geographic expansion. Domestic incidence may be increasing in the setting of global travel and immunosuppression. United States dermatologists may play a central role in early detection and initiation of appropriate treatment, leading to decreased morbidity and mortality.

Dermatologic Fungal Neglected Tropical Diseases-Part II. Management and Morbidity.

In this part 2 of a 2-part continuing medical education series, the management, outcomes, and morbidities for fungal skin neglected tropical diseases (NTDs), including eumycetoma, chromoblastomycosis, paracoccidioidomycosis, sporotrichosis, emergomycosis, talaromycosis, and lobomycosis are reviewed. While fungal skin NTDs are associated with poverty in resource-limited settings, they are more often associated with immunosuppression and global migration in the United States. These infections have a high morbidity burden, including disfigurement, physical disability, coinfection, malignant transformation, mental health issues, and financial impact. For most fungal skin NTDs, management is difficult and associated with low cure rates. Dermatologists play a central role in initiating appropriate treatment early in disease course in order to improve patient outcomes.

Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement.

Importance: Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea. Objective: To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice. Evidence Review: A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set. Findings: The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting. Conclusions and Relevance: This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

The Curious Case of a Painful Leg Ulcer.

Sickle cell disease is a condition that can involve numerous organ systems secondary to vascular occlusion. Herein, we present a case of a 21-year-old male with sickle cell disease requiring long-term hydroxyurea therapy. Upon migrating to the United States from Yemen, the patient developed a rapidly progressive, exquisitely painful ulcer on his right lower extremity. Given his country of origin, a broad differential, including select infectious diseases, was essential. Moreover, establishing the unequivocally correct diagnosis was crucial to determine proper and safe therapy. Ultimately, a lesional biopsy demonstrated numerous sickled red blood cells occluding blood vessels, leading to the diagnosis of sickle cell disease-related leg ulceration.

Chromoblastomycosis Presenting as a Solitary Lesion in a Non-endemic Region.

Chromoblastomycosis is a neglected tropical disease typically found in endemic tropical and subtropical regions. Herein, we discuss a rare case of a 55-year-old man in Texas who presented with an exophytic papule on the forearm, diagnosed to have chromoblastomycosis by shave biopsy and subsequent histopathological analysis. Treatment options for chromoblastomycosis include long-term oral antifungal therapy with itraconazole, physical modalities such as heat therapy in conjunction with oral antifungals, and surgical interventions such as cryosurgery or surgical excision.

A case of filgrastim-induced neutrophilic dermatosis of the dorsal hands in a patient with Felty Syndrome.

Neutrophilic dermatosis of the dorsal hands (NDDH) is a variant of Sweet syndrome that presents with erythematous bullae, papules/plaques, or pustules on the dorsal hands. It is most commonly associated with hematologic and solid organ malignancies, though cases of NDDH associated with inflammatory bowel disease, rheumatologic disorders, and medication exposure have also been described in the literature. Felty syndrome is a rare complication of long-standing rheumatoid arthritis characterized by neuropathy, splenomegaly, and neutropenia. Granulocyte colony stimulating factors (e.g., filgrastim) can be utilized to rescue the neutropenia observed in Felty syndrome, but this treatment may subsequently cause Sweet syndrome. Herein, we present a 64-year-old man with Felty syndrome and a complex medical history who presented with sudden onset, painful blisters located on the dorsal and palmar aspects of his bilateral hands. Given the patient's past medical history, a broad differential diagnosis, including disseminated fungal and viral infection was initially considered. A punch biopsy of the skin lesion disclosed neutrophilic dermatosis, which together with laboratory data satisfied the von den Driesch criteria for Sweet syndrome. As the lesions were localized exclusively on the patient's hands, the qualification of NDDH was also endorsed.

"The Raven Himself Is Hoarse:" Candida dubliniensis fungemia manifesting as an eschar.

A 65-year-old man with diabetes, end-stage renal disease on hemodialysis, coronary artery disease, and a prosthetic aortic valve. He presented to the emergency department with hypothermia (96.6°F), several weeks of anorexia and chills, and bilateral lower extremity tissue necrosis with erythema and edema (Figure 1A). He had a peripherally inserted central catheter (PICC) line 8 weeks prior placed at another hospital for treatment of cellulitis. Laboratory results revealed anemia, azotemia, and leukocytosis (19,200 WBCs/mm3), and he was admitted for sepsis of unknown etiology. (SKINmed. 2022;20:213-214).

Future Fungal Fighters in Dermatology: Novel Antifungal Drug Pipeline.

Over the last decade, major advances in antifungal drug development have occurred. Novel drugs in the pipeline include ME1111, MAT2203, rezafungin, ibrexafungerp, olorofim, fosmanogepix, MGCD290, VT-1161, NP213, T-2307, aureobasidin A, and nikkomycin Z. While most of these “future fungal fighters” have been developed to address invasive fungal infections (IFI), there is potential for dermatologists to benefit as these drugs may be adapted for superficial infections. Here, we review the major developments in novel antifungals and examine the ways in which dermatologists may gain from these recent innovations. J Drugs Dermatol. 2022;21(5):496-501. doi:10.36849/JDD.6373.

Public interest in skin lightening across the United States, January 2015-December 2020.

Skin lightening is a popular practice across the world, especially in India, the Philippines and other Asian countries, and some Caribbean nations. It is a dangerous trend, as some of the products used to achieve a lighter skin tone have been shown to often contain unsafe chemicals. In this article, we examine trends in consumer interest in skin lightening using a Google Trends query of 4 search terms: "skin lightening," "skin brightening," "skin whitening," and "skin bleaching," across the United States from 2015 to 2020, and demonstrated that it is most popular in states with diverse populations, including a high percentage of black and Asian Americans.

Therapeutic Approaches and Special Considerations for Treating Molluscum Contagiosum.

Molluscum contagiosum (molluscum) is a common skin condition, especially in children, yet treatment approaches by US health care practitioners vary widely. A dearth of clinical data from large, well-controlled studies has resulted in significant gaps in knowledge, including treatment guidelines and algorithms. As of this writing, there are no FDA-approved treatments for molluscum. The objective of this review is to provide practitioners with expert, evidence-based information and guidance about treatment approaches for, and the special circumstances faced by, patients with molluscum. To this end, a group of five pediatric and adult dermatologists collectively identified treatments and special considerations they felt were most commonly used to treat molluscum. Hence, in the first part of the review, seven treatment approaches identified as the most important to review (e.g., curettage, cantharidin) are discussed in terms of their mechanisms of action, supporting clinical data, and rationale for use. Each treatment approach concludes with a “clinical pearls” section, which summarizes the group’s experiences with the treatment. In the second part, five special considerations (e.g., atopic dermatitis, skin of color) are discussed with supporting clinical data and are also followed by a “clinical pearls” summary. J Drugs Dermatol. 2021;20(11): 1185-1190. doi:10.36849/JDD.6383.

Intramuscular lipoma of the scapular region.

Intramuscular lipomas are rare, benign soft tissue neoplasms characterized by infiltrative growth into muscle tissue or between muscle fibers. These benign tumors can present similarly to malignant soft tissue neoplasms, such as liposarcomas. Unlike subcutaneous lipomas, intramuscular lipomas require diagnostic imaging to better distinguish the tumor and rule out alternative, malignant etiologies. It is imperative that dermatologists are able to identify this rare lipoma variant and have a thorough understanding of the diagnosis, imaging, and treatment options for this uncommon soft tissue tumor. Our case serves as a reminder for dermatologists to be cognizant of this rare tumor and aware of the importance of diagnostic testing in ruling out similarly-presenting, soft tissue malignancies.

Sexually Transmitted Diseases in the COVID-19 Era.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is an infectious disease of recent origin with high transmissibility and mortality. The resulting COVID-19 pandemic has impacted the United States the most, in terms of the number of confirmed cases and fatalities. How other aspects of public health will be impacted by this disease has yet to be fully realized. Sexually transmitted diseases (STDs), already a major public health crisis, will likely be significantly affected by this pandemic. We address some of the potential implications for STDs in the setting of widespread COVID-19, discussing the sexual transmission of COVID-19 itself, STD co-infection with COVID-19, and changes in STD prevalence secondary to COVID-19. (SKINmed. 2020;18:210-212).

iPLEDGE Must Abstain from Abstinence.

Isotretinoin has unmatched efficacy in the treatment of acne. However, because isotretinoin is a teratogen that can cause profound birth defects, the iPLEDGE program regulates the drug's distribution in the United States. To minimize fetal exposure to isotretinoin, the program requires that female patients capable of becoming pregnant use two forms of contraception or commit to abstinence while using this therapy. This manuscript argues that iPLEDGE should be revised to remove abstinence as an acceptable contraceptive option in the face of evidence that disputes its efficacy. All patients, regardless of reported sexual activity, should be required to use data-proven contraception. Potential benefits of the proposed change (iPLEDGE-R) include reducing the number of isotretinoin pregnancies, increasing patient privacy protection, and standardizing patient care. Further investigation needs to guide additional strategies to achieve the program's public health goal; however, the ethical and pragmatic advantages of iPLEDGE-R merit consideration.