Idiopathic pure sudomotor failure: A review and two cases.

Idiopathic pure sudomotor failure (IPSF) is a rare disease characterized by acquired impairment in total body sweating despite exposure to heat or exercise. Its etiology is unknown but thought to involve defective cholinergic receptors on eccrine sweat glands. This article reviews the epidemiology, pathophysiology, presentation, and management of IPSF. Additionally, we report two cases of IPSF treated with multimodal therapy, including stacked antihistamine regimens and omalizumab, resulting in symptom improvement. This is the first report of treatment of IPSF with omalizumab, although its benefit is uncertain and requires further study.

Management of common scabies and postscabetic itch in adults: Lessons learned from a single-center retrospective cohort study.

BACKGROUND: Common scabies can be difficult to diagnose and treat. There are limited data on the clinical characteristics of patients who may benefit from combined topical permethrin plus oral ivermectin. Postscabetic itch is common, but there is scant data describing its prognosis and management. OBJECTIVE: This study describes the clinical characteristics and evaluates treatment outcomes of participants with common scabies treated with combined topical permethrin plus oral ivermectin and describes the prognosis and management of postscabetic itch. METHODS: We conducted a single-center retrospective cohort study of participants with common scabies treated with combined topical permethrin plus oral ivermectin therapy and topical permethrin only. Participants previously treated with permethrin and/or ivermectin were excluded. The primary outcome was clinical outcome at follow-up, categorized as cure, worsening, or no change. Secondary outcomes included time from treatment initiation to cure, duration of follow-up after cure, recurrence rate, frequency of postscabetic itch, and duration of postscabetic itch. RESULTS: Of 55 participants treated with combined topical permethrin plus oral ivermectin, 49 (89%) achieved cure, 5 (9%) had no change, and 1 (2%) had worsening disease. Of 48 participants treated with topical permethrin only, 46 (96%) achieved cure, 2 (4%) had no change, and 0 (0%) had worsening disease. Thirty-five participants (34%) experienced postscabetic itch for 52.5 days (interquartile range, 28-135). More participants in the older (mean: 55 years; standard deviation: 21 years; p = .002) combined treatment group experienced postscabetic itch than in the younger (mean: 42 years; standard deviation: 19 years) permethrin-only treatment group (42% vs. 25%; p = .072). CONCLUSION: These findings support the use of combined topical permethrin plus oral ivermectin therapy in treating common scabies, highlight that postscabetic itch can persist for longer than previously reported, and reveal a potential relationship between older age and postscabetic itch.

Expression of programmed cell death ligand 1 and programmed cell death 1 in cutaneous warts.

BACKGROUND: Cutaneous warts have high prevalence and cause significant morbidity. Understanding the mechanisms by which warts evade the immune system could lead to targeted and improved treatments. OBJECTIVE: To determine whether cutaneous warts express programmed cell death ligand 1 (PD-L1) and to characterize the expression of programmed cell death 1 (PD-1) within the immune infiltrate of inflamed lesions. METHODS: In total, 44 biopsies of cutaneous warts were retrieved from the Department of Dermatopathology archives of the University of California, San Francisco. Biopsies were stained with hematoxylin and eosin and PD-L1 monoclonal antibody, and biopsies of inflamed lesions were stained with PD-1 monoclonal antibody. RESULTS: PD-L1 was expressed on keratinocytes in cases of verrucae vulgares (12/30, 40%) and myrmecia (7/14, 50%) and was associated with an interface inflammatory reaction. PD-1 was expressed by the inflammatory infiltrate in verrucae vulgares (21/24, 88%) and myrmecia (5/8, 63%). LIMITATIONS: This was a retrospective observational study conducted at a single institution. CONCLUSION: Many cutaneous warts express PD-L1, suggesting that human papillomavirus might use this pathway to promote immune dysfunction. This discovery helps explain the recalcitrance of warts to current therapies and provides a rationale for investigating anti-PD-1 immunotherapy as a potential treatment for warts.

Cultural competence for the 21st century dermatologist practicing in the United States.

Significant health disparities exist among under-represented minorities in the Unites States, which can partially be accounted for by the quality of patient-physician interaction. A distinguishing factor of this interaction is the ability of the provider to demonstrate cultural competence, or address the social, cultural, and community influences on healthcare behaviors and incorporate these elements into patient care. However, this practice has yet to be universally implemented in our healthcare system. These factors become even more important as the racial, ethnic and cultural distribution of the United States population changes. Multiple studies have suggested that cultural competence of the health care provider and staff leads to improved patient adherence, satisfaction, and ultimately, health outcome. Cultural competence in the workplace also leads to efficient and cost-effective healthcare and better community integration into healthcare systems. The purpose of this review is to help dermatologists understand the benefits of culturally competent care for their patients and themselves and identify methods and resources to achieve this goal.

A decade of burn unit experience with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Clinical pathological diagnosis and risk factor awareness.

Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) is a rare and often fatal spectrum of mucocutaneous diseases usually attributable to severe adverse drug reactions. Burn units are referral centers for patients at the most extreme end of the disease continuum. Our burn center admits a much higher percentage of TEN (>30% BSA) cases than reported in most prior reviews. The purpose of this study was to analyze the diagnostic and prognostic value of variables collected on referred SJS/TEN patients. We retrospectively analyzed 94 patients admitted to our unit with a presumptive SJS/TEN diagnosis made in most cases by the referring center. Most of the diagnoses were clinical. Fifty of the 94 patients underwent biopsy when the clinical diagnosis was questionable. Of the 50 patients who underwent biopsy, 18 (36%) received an alternative diagnosis. Analysis was therefore limited to 76 patients, i.e. 44 patients felt to have firm clinical diagnoses plus 32 patients with diagnoses confirmed by biopsy. Mean age was 54.3 years (17-93) and overall gender ratio was 43 F vs. 33 M (56.6% vs. 43.4%). Mean LOS was 15.2 days (1-48) and overall mortality was 23.7% (18/76). Univariate analysis revealed percent body surface area (%BSA) did not show statistically significant association with mortality. Histopathological correlation for diagnosis is not standardized across institutions worldwide. Due to challenges in the diagnosis of SJS/TEN and the high incidence of error in clinical diagnosis, it is recommended that all patients with presumed SJS/TEN receive skin biopsies with H&E and direct immunofluorescence. We propose a diagnostic approach in order to address this need. Lack of association between %BSA and mortality suggests that all biopsy-proven SJS/TEN cases belong in specialty centers due to the unstable nature of the disease and risk for rapid progression.

Imiquimod-induced subacute cutaneous lupus erythematosus-like changes.

Imiquimod is a topical immunomodulator used to treat genital warts and cutaneous malignancies that exerts its effects via induction of proinflammatory cytokines through activation of toll-like receptor (TLR) 7. Although subacute cutaneous lupus erythematosus (SCLE) has been reported in association with multiple systemic medications, SCLE in patients treated with topical agents has not been widely reported. We report the case of a 50-year-old woman with local induction of lesions that clinically and histologically resembled SCLE following treatment with topical imiquimod.

Cutaneous granulomas in the setting of primary immunodeficiency: a report of four cases and review of the literature.

IMPORTANCE: Cutaneous granulomas without an identifiable infectious etiology are a rare manifestation of primary immunodeficiency (ID). These cutaneous lesions can be misdiagnosed, often as sarcoidosis, when the skin findings precede the diagnosis of immunodeficiency. OBJECTIVE: We present four cases from our institution and review the literature in order to emphasize the clinical relevance of this association, discuss the histologic and immunohistochemical features, and explore possible pathogenic mechanisms of granuloma formation. EVIDENCE REVIEW: We retrospectively reviewed case reports of all patients presenting with cutaneous granulomas in the setting of primary immunodeficiency. Cases with insufficient information to confirm an immunodeficiency state were excluded. Four patients from our clinic were included, for 54 total cases. FINDINGS: The majority of cutaneous granulomas are seen in three types of immunodeficiencies: ataxia-telangiectasia, severe combined immunodeficiency, and combined variable immunodeficiency. Twenty-six percent of patients developed cutaneous granulomas prior to their immunodeficiency diagnosis. Histologically, various granulomatous patterns have been described. Immunohistochemistry revealed a CD4+/CD8+ lymphocyte ratio of less than or equal to 1 in our four patients, which may help differentiate cutaneous granulomas in primary ID from sarcoidal granulomas that typically show a CD4+ predominance. CONCLUSIONS AND RELEVANCE: Cutaneous granulomas are a rare manifestation of primary ID and occur predominantly in immunodeficiencies that affect T and B cell compartments.

Non-tuberculous mycobacterial infections following cosmetic laser procedures: a case report and review of the literature.

Skin infections are not uncommon after cosmetic laser procedures. Infection rates following ablative laser resurfacing procedures are reported to be as high as 7.6%, compared to 1.9% for fractional ablation. An infrequent yet important infectious complication of ablative laser treatment is that caused by non-tuberculous mycobacteria (NTM).

Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches.

Atopic dermatitis is a common, chronic inflammatory dermatosis that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this final section, treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed. Suggestions on use are given based on available evidence.

Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents.

Atopic dermatitis is a chronic, pruritic inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in atopic dermatitis management and care, providing recommendations based on the available evidence. In this third of 4 sections, treatment of atopic dermatitis with phototherapy and systemic immunomodulators, antimicrobials, and antihistamines is reviewed, including indications for use and the risk-benefit profile of each treatment option.