Pleomorphic Dermal Sarcoma With Metastasis to the Lung: A Case Report.

ABSTRACT: Atypical fibroxanthoma and pleomorphic dermal sarcoma (PDS) are dermal malignant mesenchymal tumors that lie at the ends of the same disease spectrum. Clinically indistinguishable from atypical fibroxanthoma, PDS has a more aggressive course with significantly higher rate of local recurrence and metastases. Histological findings that favor a PDS include subcutaneous invasion, tumor necrosis, lymphovascular invasion, and/or perineural infiltration. Herein, we report a case of PDS with metastasis to the lung. Our report highlights the risk of local recurrence and metastatic spread in this cutaneous tumor and the importance of distinguishing this entity from its less aggressive counterpart.

Cannabinoids for the treatment of chronic pruritus: A review.

Medical marijuana is becoming widely available to patients in the United States, and with recreational marijuana now legalized in many states, patient interest is on the rise. The endocannabinoid system plays an important role in skin homeostasis in addition to broader effects on neurogenic responses such as pruritus and nociception, inflammation, and immune reactions. Numerous studies of in vitro and animal models have provided insight into the possible mechanisms of cannabinoid modulation on pruritus, with the most evidence behind neuronal modulation of peripheral itch fibers and centrally acting cannabinoid receptors. In addition, human studies, although limited due to differences in the cannabinoids used, disease models, and delivery method, have consistently shown significant reductions in both scratching and symptoms in chronic pruritus. Clinical studies have shown a reduction in pruritus in several dermatologic (atopic dermatitis, psoriasis, asteatotic eczema, prurigo nodularis, and allergic contact dermatitis) and systemic (uremic pruritus and cholestatic pruritus) diseases. These preliminary human studies warrant controlled trials to confirm the benefit of cannabinoids for treatment of pruritus and to standardize treatment regimens and indications. In patients who have refractory chronic pruritus after standard therapies, cannabinoid formulations may be considered as an adjuvant therapy where it is legal.

The impacts of oral health symptoms, hygiene, and diet on the development and severity of psoriasis.

Numerous studies have suggested a correlation between oral health, the oral microbiome, and various dermatologic conditions, particularly psoriasis. In this study, we utilize a specially designed questionnaire administered to 265 patients at The Ohio State University's dermatology clinics to explore the relationship between psoriasis and a combination of factors that included dietary habits, oral health, and oral hygiene practices. Age, family history of psoriasis, previous diagnosis of strep throat or rheumatoid arthritis, and oral pain or discomfort experienced within the last 12 months were all found to be significant predictors of psoriasis. Additionally, higher body mass index scores, poor gum health, and speech difficulties related to dental problems were all correlated with more severe psoriasis symptoms. Conversely, patients who reported consuming fresh fruit at least once a day experienced milder symptoms. Our goal is to develop a better understanding of how and why psoriasis incidence is correlated with some of the oral health factors under review.

Polypoid amelanotic melanoma: a diagnostic challenge.

Melanoma is a highly aggressive cutaneous malignancy with considerable risk for metastasis. These malignant tumors are typically pigmented given that they arise from melanocytes capable of producing melanin. Amelanotic melanomas are a rare variant and there is often a delay in diagnosis owing to lack of pigmentation. Although there are various presentations of amelanotic melanoma, a solitary polypoid nodule is unusual and warrants further reporting. Herein, we present a patient with a 3-year history of a tender firm, skin-to-pink colored polypoid nodule. Excisional biopsy and work up showed an aggressive amelanotic melanoma with depth of 20mm and nodal metastasis consistent with stage IIIC disease. This case highlights the necessity of recognition and prompt management of this rare subtype of melanoma.

Dermatoses of pregnancy.

The dermatoses of pregnancy represent a distinct heterogenous group of cutaneous disorders that can impact the health of the pregnant woman and potentially the fetus. The current classification of pregnancy-specific cutaneous disorders is reviewed, along with important clinical features. Advances in management of these disorders, along with fetal implications, are discussed. The diagnosis of these disorders is challenging, but important clinical features can aid in diagnosis. There have been important advances in the management of these disorders and better understanding of potential fetal risks. Early recognition is critical for appropriate care.

Hair loss in women.

Hair loss is a common cause of morbidity for many women. As a key member of the woman's health care team, the obstetrician/gynecologist may be the first person to evaluate the complaint of hair loss. Common types of nonscarring hair loss, including female pattern hair loss and telogen effluvium, may be diagnosed and managed by the obstetrician/gynecologist. A systematic approach to diagnosis and management of these common forms of hair loss is presented.

Sexually transmitted diseases.

Sexually transmitted diseases (STDs) continue to be a global epidemic with significant risk of morbidity/mortality for the fetus. STDs with prominent cutaneous findings including condylomata acuminata, genital herpes infections, and syphilis are reviewed. Important clinical cutaneous findings help aid early diagnosis and facilitate treatment. Condylomata acuminata have the potential of causing cervical cancer, anogenital cancer, and oropharyngeal cancer. Significant advances have been made in human papilloma virus vaccinations and treatment. Genital herpes infection can produce significant physical and emotional distress to the patient and significant potential harm to the fetus. Early clinical recognition of STDs and their appropriate management is critical.

Considerations for cutaneous physiologic changes of pregnancy that fail to resolve postpartum.

Pregnancy prompts many adaptive and unique physiologic modifications, with cutaneous changes being possibly the most noticeable. These cutaneous changes are of interest to physicians, since they must be diagnosed as anticipated normal physiologic changes or potentially harmful and managed accordingly. Research has been conducted on physiologically normal and abnormal cutaneous manifestations of pregnancy but is lacking in regard to the persistence of these changes after delivery. This prompts the question as to whether these are normal physiologic changes taking longer to resolve, abnormal changes that may have been previously misdiagnosed, or a separate underlying change that is incorrectly attributed to a common dermatosis caused by pregnancy. Some of the conditions that may persist longer than expected during or after pregnancy, and thus require further workup for an underlying condition, include telogen effluvium, severe hirsutism, palmar erythema, and striae. The objective of this review is to focus on these four common cutaneous physiologic changes of pregnancy, and what to consider when they do not resolve as expected.

Long-term Remission of Pyoderma Gangrenosum, Acne, and Hidradenitis Suppurativa Syndrome.

Pyoderma gangrenosum (PG), acne, and hidradenitis suppurativa (HS)(PASH) syndrome is an autoinflammatory condition that is poorly characterized in the literature, and achieving extended remission has proven difficult. We report the case of a patient with a history of cystic acne and HS who was referred to dermatology for evaluation of refractory PG of 18 months' duration. After therapeutic refinement, remission was achieved and maintained for 4 years using adalimumab and cyclosporine. Treatment success generally is only achieved using multimodal therapies targeting various molecules of the innate immune system, suggesting that PASH syndrome may involve multiple pathways of the inflammatory cascade; however, current understanding of the disease mechanism is scarce. The distinct genotypic and immunologic abnormalities of PASH syndrome require further study to uncover the mechanisms that therapeutic regimens aim to interrupt. Multimodal therapy is necessary to control the autoinflammatory nature of this disease, and further reports of therapeutic successes are essential for advancement in understanding this debilitating condition.

Tinea capitis among children in the Columbus area, Ohio, USA.

Tinea capitis is a fungal infection of the hair follicles of the scalp. In the US, the most common organisms have traditionally been Trichophyton tonsurans, and occasionally Microsporum canis. This study was designed to examine patterns of organisms causing tinea capitis and determine factors associated with infection. A retrospective database analysis was conducted to locate records of patients with tinea capitis from May 2001 to May 2006 at Nationwide Children's Hospital in Columbus, OH. Descriptive statistics, frequency analysis, chi-squared test, and Student's t-test were performed to evaluate types of causative organisms and associated patient characteristics. One hundred and eighty-nine charts of patients with a positive scalp culture for tinea capitis were located. Trichophyton tonsurans (88.9%) was the foremost causative agent followed by Trichophyton violaceum (4.2%). Tinea capitis was more prevalent among African Americans and was more common in urban areas (P < 0.05). Children of African descent inhabiting urban settings were most vulnerable to tinea capitis. The most common organism isolated in this retrospective study was T. tonsurans. Trichophyton violaceum and Trichophyton soudanense were also isolated, which are not commonly reported causes of tinea capitis in the US.

Intravenous immunoglobulin therapy for scleromyxedema: a case report and review of literature.

Scleromyxedema is a chronic, idiopathic disorder characterized by cutaneous dermal mucin deposition in association with increased dermal collagen and absence of thyroid disease. The clinical features involve sclerosis of skin with numerous, 2-3 mm, firm, waxy, papules in a symmetrical distribution pattern. The skin lesions may progress to widespread and indurated plaques resulting in patient disability via decreased mobility, sclerodactyly and microstomia. Abnormalities in the muscular, neurologic, rheumatologic, pulmonary, renal and cardiovascular systems may accompany the cutaneous lesions. Multiple attempts at therapeutic interventions have failed due to inconsistent, unsatisfactory results and/or severe adverse effects. Herein, the authors describe a case of scleromyxedema successfully treated with high-dose intravenous immunoglobulin (hdIVIG).

Multicentric reticulohistiocytosis: A case report and review of the literature.

We report a case of multicentric reticulohistiocytosis (MRH) demonstrating classic clinical and histologic findings. This rare idiopathic disease is manifested by severe destructive polyarthritis and papulonodular mucocutaneous lesions. The characteristic clinical and histologic findings are discussed as well as the workup and treatment of the disease.

The role of Malassezia in atopic dermatitis affecting the head and neck of adults.

Atopic dermatitis is a common chronic skin condition. A subset of patients with head and neck dermatitis may have a reaction to Malassezia flora fueling their disease. Although there are no documented differences in Malassezia species colonization, patients with head and neck atopic dermatitis are more likely to have positive skin prick test results and Malassezia-specific IgE compared with healthy control subjects and patients with atopy without head and neck dermatitis. There is no clear relationship with atopy patch testing. The reaction to Malassezia is likely related to both humoral- and cell-mediated immunity. Clinically, Malassezia allergy may be suspected in patients with atopic dermatitis and: (1) head and neck lesions; (2) exacerbations during adolescence or young adulthood; (3) severe lesions recalcitrant to conventional therapy; and (4) other atopic diseases. There is literature to suggest that these patients will benefit from a 1- to 2-month course of daily itraconazole or ketoconazole followed by long-term weekly treatment.

Infectious complications in patients with psoriasis and rheumatoid arthritis treated with antitumor necrosis factor agents and methotrexate.

Treatment of patients with moderate-severe psoriasis and/or psoriatic arthritis includes systemic biologic, antimetabolite, and immunosuppressive therapy. However, adverse events such as serious infectious complications must be considered before starting therapy and throughout treatment. The authors describe the case of a male on combination etanercept and methotrexate for psoriasis and psoriatic arthritis for years who developed a spontaneous epidural abscess with resulting quadriplegia. In addition, a review of the literature was performed looking at the risk of serious infectious complications with antitumor necrosis factor (anti-TNF) monotherapy or combination therapy with methotrexate fro the treatment of psoriasis and rheumatoid arthritis. Serious infectious risk does not appear to be increased with etanercept or other anti-TNF agents either alone or in combination with methotrexate. Nevertheless, clinicians are cautioned to carefully weigh the risks and benefits of treating with anti-TNF agents in patients who are prone to infection.

Bullous pemphigoid precipitated by galantamine hydrobromide.

Bullous pemphigoid (BP) is an acquired autoimmune disease commonly attributed as idiopathic, especially in elderly patients, characterized by subepidermal vesicles and bullae with linear deposits of IgG autoantibodies and complement along the epidermal basement membrane. It also is now commonly accepted that BP can be caused by or associated with drug therapy. We report a case of drug-induced BP (DIBP) likely due to galantamine hydrobromide, a competitive and reversible acetylcholinesterase inhibitor used in the treatment of mild to moderate Alzheimer dementia.

Subcutaneous alemtuzumab for Sézary Syndrome in the very elderly.

Sézary Syndrome (SS) is an aggressive T-cell malignancy often presenting in advanced age and associated with poor prognosis. There is no standard therapy and because of co-morbidities, elderly patients are particularly challenging to treat. Alemtuzumab is an anti-CD52 monoclonal antibody that has activity in SS but is profoundly immunosuppressive, leading to great hesitation about its use in older patients. We treated five octogenarian patients with SS with subcutaneous (SQ) alemtuzumab, at relapse or as initial therapy, for 5-9 weeks. With the exception of transient grade 1-2 hematological toxicity and asymptomatic cytomegalovirus (CMV) (two patients) and Epstein-Barr virus (EBV) (one patient) reactivation, no other toxicities were observed. The clinical and hematological complete response (CR) rate was 100%. Three patients achieved durable responses (8+ to 17+ months). Alemtuzumab was safely administered and showed significant activity in very elderly SS patients.

Metastatic basal cell carcinoma presenting with unilateral upper extremity edema and lymphatic spread.

Basal cell carcinoma (BCC), the most common human malignancy, metastasizes in 0.0028% to 0.5% of cases, usually to the lymph nodes, lungs, bones, and skin. After metastatic spread of BCC, survival averages 1 to 2 years. Chemotherapy, radiotherapy, and surgery are treatment options. We describe metastatic basal cell carcinoma to the skin presenting with unilateral upper extremity edema.

Pruritus in Pregnancy and Its Management.

Pruritus in pregnancy can be a source of significant discomfort in the pregnant patient. Some cases are associated with pregnancy-specific dermatoses, although some patients experience a flare of a preexisting dermatosis. Severe pruritus may be a manifestation of a pregnancy-specific dermatosis associated with increased fetal risks and complications. Early accurate diagnosis and appropriate management are important. Examination often reveals important clinical findings, aiding accurate diagnosis. Pemphigoid gestationis often presents with periumbilical involvement, whereas polymorphic eruption of pregnancy spares the umbilicus and presents in the striae distensae. Intrahepatic cholestasis of pregnancy is associated with intense pruritus of the palms.