A Rare Presentation of Dermatofibrosarcoma Protuberans of the Scalp Treated with "Slow-Mohs" Micrographic Surgery.

Dermatofibrosarcoma protuberans (DFSP) is a rare, fibrohistiocytic tumor with intermediate malignancy.1 While these tumors are slow-growing and only metastasize in 6% of cases,2 they are often locally destructive, with relatively high local recurrence rates after initial excision. Overall annual incidence rates in the US are 0.8-4.1 per million person-years,2 though incidence among African Americans is nearly double that of Caucasians.3 DFSP is most commonly seen on the trunk (42-50%), followed by the extremities (30-42%) and, rarely, on the head and neck (10-15%).2,4 Other studies report that DFSP of the scalp accounts for under 5% of total cases.5 However, the head and neck region is reported to have the highest tendency to recur locally, roughly 50-75% of cases.4 Further, DFSP tumors on the scalp have the potential to metastases to the brain,4 thus highlighting the importance for these tumors to be correctly diagnosed and treated early on. Partly due to its rarity and also its tendency to mimic other mainly benign lesions clinically, DFSP is often misdiagnosed, leading to years of delay in proper treatment and otherwise likely avoidable sequelae.6 We describe a rare presentation of DFSP on the scalp of a 45-year-old African American woman successfully treated with "slow-Mohs" micrographic surgery. We also discuss the most common misdiagnoses for DFSP and scenarios when this tumor should be included in the differential and subsequent work-up.J Drugs Dermatol. 2022;21(5):534-535. doi:10.36849/JDD.6719.

Bullosis Diabeticorum: A Neglected Bullous Dermatosis.

A 75-year-old African-American man presented with a 3-year history of painless, fluid-filled blisters, for which his primary care physician had treated him with doxycycline, cephalexin, and topical corticosteroids, with no significant improvement. The blisters had ruptured spontaneously and healed with scarring. He denied antecedent trauma. His medical history was remarkable for insulin-dependent type 2 diabetes mellitus, hypertension, hypercholesterolemia, primary cutaneous melanoma status-post excision, and breast cancer status-post mastectomy and chemotherapy. Physical examination revealed nontender bullae, measuring up to 4 cm × 3 cm and containing serous fluid, on the anterior portion of both tibias (Figure 1). The Nikolsky sign was negative. There was no evidence of surrounding inflammation. A biopsy revealed subepidermal bullae formation with sparse inflammatory infiltrate (Figure 2). Direct and indirect immunofluorescence studies were negative for immunoglobulin (Ig) G, IgA, IgM, complement C3, C5b-9, and fibrinogen deposition. Culture of the bullous fluid was negative.

Development and Implementation of a Situation Awareness Workshop to Advance Safe Practice in Novice Nurses.

The current study evaluated the effectiveness of a workshop designed to provide nurses (n = 6) with the means to improve their situation awareness. The nurses participated in a full-day workshop in which their situation awareness performance was measured before and after using the Situation Awareness Global Assessment Technique. Following the workshop, nurses demonstrated improvement in their perception of relevant cues, comprehension of what the combination of cues means, and projection of the patient's future status. The implications of situation awareness education for health-care professionals are discussed.

Modelling the chemistry of Mn-doped MgO for bulk and (100) surfaces.

We have investigated the energetic properties of Mn-doped MgO bulk and (100) surfaces using a QM/MM embedding computational method, calculating the formation energy for doped systems, as well as for surface defects, and the subsequent effect on chemical reactivity. Low-concentration Mn doping is endothermic for isovalent species in the bulk but exothermic for higher oxidation states under p-type conditions, and compensated by electrons going to the Fermi level rather than cation vacancies. The highest occupied dopant Mn 3d states are positioned in the MgO band gap, about 4.2 eV below the vacuum level. Surface Mn-doping is more favourable than subsurface doping, and marginally exothermic on a (100) surface at high O2 pressures. For both types of isovalent Mn-doped (100) surfaces, the formation energy for catalytically important oxygen defects is less than for pristine MgO, with F0 and F2+-centres favoured in n- and p-type conditions, respectively. In addition, F+-centres are stabilised by favourable exchange coupling between the Mn 3d states and the vacancy-localised electrons, as verified through calculation of the vertical ionisation potential. The adsorption of CO2 on to the pristine and defective (100) surface is used as a probe of chemical reactivity, with isovalent subsurface Mn dopants mildly affecting reactivity, whereas isovalent surface-positioned Mn strongly alters the chemical interactions between the substrate and adsorbate. The differing chemical reactivity, when compared to pristine MgO, justifies further detailed investigations for more varied oxidation states and dopant species.

Mucocutaneous manifestations of helminth infections: Trematodes and cestodes.

In the 21st century, despite increased international travel for vacation, work, and medical missions and immigration into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. It has been estimated that 20% to 70% of international travelers suffer from some travel-related health problem. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on cutaneous diseases caused by helminth infections. Part I of the review focused on nematode infections; part II will focus on trematode and cestode infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

Mucocutaneous manifestations of helminth infections: Nematodes.

In the 21st century, despite increased globalization through international travel for business, medical volunteerism, pleasure, and immigration/refugees into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on the cutaneous manifestations of helminth infections and is divided into 2 parts: part I focuses on nematode infections, and part II focuses on trematode and cestode infections. This review highlights the clinical manifestations, transmission, diagnosis, and treatment of helminth infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

Interleukin-23 in the pathogenesis and treatment of psoriasis.

In the past three decades, major advances have been made in understanding the pathogenesis of psoriasis. The currently accepted theory is that T-cell mediated immune dysregulation triggers keratinocyte hyperproliferation in psoriasis. Recent research indicates that the Th17/interleukin (IL)-23 pathway plays a prominent role in the amplification phase of psoriasis. The discovery of the Th17/ IL-23 pathway provides targets for new drug development. This review focuses on the role of IL-23 in psoriasis pathogenesis and the current therapies targeting IL-23 that are in clinical trials.

Current and emerging drugs for acute bacterial skin and skin structure infections: an update.

INTRODUCTION: Antibiotic resistance, the emergence of multidrug-resistant bacteria and the exponential rise of methicillin-resistant Staphylococcus aureus (MRSA) acute bacterial skin and skin structure infections (ABSSSI) pose a great threat to the public health. In order to combat these threats, development of new antibiotics is vital and measures to decrease antibiotic resistance should be prioritized. AREAS COVERED: This manuscript provides an overview of the current FDA-approved antibiotics and the antibiotics in development for MRSA ABSSSI. EXPERT OPINION: A great need exists currently for novel antibiotics to combat multidrug-resistant MRSA. As clinicians, it is imperative to implement proper management in order to reduce antibiotic resistance.

Bloodroot associated eschar.

We present a case of a 60-year-old woman who, after using a blemish cream purchased at a health store, presented to our clinic with a large eschar on the right neck. The active ingredient in this cream was found to be Sanguinaria canadensis, a known escharotic. This substance is popularly marketed as a natural remedy for a host of skin diseases such as blemishes, moles, warts, skin tags, basal cell carcinomas, squamous cell carcinomas, actinic keratoses, and even melanoma. The patient was treated with topical corticosteroids but is still left with a scar from the healed eschar. Dermatologists must be aware of the increasing popularity of "natural" medicinal skin cancer therapies, such as bloodroot-containing "cancer salves" and "herbal cures," and emphasize to their patients that conventional excision, micrographic surgery, electrodessication, and/or curettage are highly successful treatments for most skin cancers with little morbidity.

Dermatofibrosarcoma Protuberans Found Within Procedural Scars: A Retrospective Review at a Tertiary Referral Cancer Center.

BACKGROUND: Surgical scars are not a well-known risk factor for the development of dermatofibrosarcoma protuberans (DFSP). However, DFSP can arise within a surgical scar. OBJECTIVE: This study determined the number of DFSP found within scars from prior surgical procedures at a tertiary academic cancer center. METHODS: A retrospective data analysis was performed of all patients with biopsy-proven DFSP from January 2000 to April 2018 at MD Anderson Cancer Center (MDACC), a tertiary referral cancer center. Chart review was performed, and data were recorded for gender, race, and age of patients. We also recorded the site, location, and size of the DFSP and whether the patients had a history of prior surgery at the DFSP site. All patients had a pathologic diagnosis of DFSP at MDACC. Patients were selected from the pathology database at MDACC using the keywords "DFSP" or "dermatofibrosarcoma protuberans". A total of 458 patients were identified; however, 94 patients were excluded from the study because they were only referred to MDACC with a confirmed diagnosis of DFSP and were not seen as patients by a MDACC physician. RESULTS: Of the remaining 364 patients, 37 patients (10.1%) had either a history of a benign neoplasm or an inflammatory disease that had been evaluated or treated by either punch biopsy, shave biopsy, or minor excision at the site of DFSP (8.5%, 31 patients) or a DFSP arising within a major surgical procedural scar (1.6%, six patients). The surgical sites identified were the abdomen (four patients) and the groin (two patients). Three of the patients with a major surgical scar DFSP had prior laparoscopic surgery at the site. CONCLUSIONS: DFSPs occur at surgical scars. The development of surgical scar DFSP in 10% of our patients prompts us to postulate that the neoplasm may be associated with the malignant transformation of these scars.

Hand-foot-and-mouth disease caused by coxsackievirus A6 on the rise.

Hand-foot-and-mouth disease (HFMD) is a viral illness caused most commonly by coxsackievirus A16 (CVA16) and enterovirus 71 (EV71). The disease mainly affects pediatric populations younger than 5 years and is characterized by lesions of the oral mucosa, palms, and soles, lasting for 7 to 10 days. In recent years, CVA6 has become a major cause of HFMD outbreaks in the United States and worldwide. This strain also has been associated with adult HFMD. It affects broader demographics and causes more severe disease with unique findings compared to typical viral strands. Patients often have higher fever and longer duration of disease than typical HFMD and often present with more severe skin manifestations, spreading to a wider distribution than typical HFMD. We review the increasing prevalence of this viral illness to better characterize its clinical presentation.

Preventing the threat of credit-card fraud: Factors influencing cashiers' identification-checking behavior.

Two studies examined factors influencing cashiers' identification (ID)-checking behavior in order to inform the development of interventions to prevent credit-card fraud. In both studies, research assistants made credit purchases in various stores and noted the cashiers' ID-checking behavior. In the first study, the store type, whether the cashier swiped the credit/debit card, the amount of the purchase, and whether the credit/debit card was signed significantly influenced ID-checking behavior. In the second study, an A-B-A design was used to evaluate the impact of a "Check my ID" prompt placed on the credit/debit card. The prompt increased cashiers' ID-checking behavior from 5.9% at Baseline to 10.3% during the Intervention. When the prompt was removed, the cashiers' ID-checking behavior decreased to 7.2%. Implications for further intervention research to prevent credit-card fraud are discussed.

Deep Fungal Infections, Blastomycosis-Like Pyoderma, and Granulomatous Sexually Transmitted Infections.

Granulomatous diseases are caused by multiple infectious and noninfectious causes. Deep fungal infections can present in the skin or extracutaneously, most commonly with lung manifestations. An Azole or amphotericin B is the universal treatment. Blastomycosis-like pyoderma is a clinically similar condition, which is caused by a combination of hypersensitivity and immunosuppression. Successful treatment has been reported with antibiotics and, more recently, the vitamin A analog, acitretin. Granuloma inguinale and lymphogranuloma venereum cause ulcerative genital lesions with a granulomatous appearance on histology. The Centers for Disease Control and Prevention recommens treatment of these genital infections with doxycycline.

Cutaneous Squamous Cell Carcinomas in Organ Transplant Recipients.

Non-melanoma skin cancers represent a major cause of morbidity after organ transplantation. Squamous cell carcinomas (SCC) are the most common cutaneous malignancies seen in this population, with a 65-100 fold greater incidence in organ transplant recipients compared to the general population. In recent years, human papillomaviruses (HPV) of the beta genus have been implicated in the pathogenesis of post-transplant SCCs. The underlying mechanism of carcinogenesis has been attributed to the E6 and E7 proteins of HPV. Specific immunosuppressive medications, such as the calcineurin inhibitors and azathioprine, are associated with a higher incidence of post-transplant SCCs compared to other immunosuppressive agents. Compared to other immunosuppressives, mTOR inhibitors and mycophenolate mofetil have been associated with a decreased risk of developing post-transplant non-melanoma skin cancers. As a result, they may represent ideal immunosuppressive medications in organ transplant recipients. Treatment options for post-transplant SCCs include surgical excision, Mohs micrographic surgery, systemic retinoid therapy, adjunct topical therapy, electrodessication and curettage, and radiation therapy. This review will discuss the epidemiology, risk factors, and management options of post-transplant SCCs. In addition, the underlying mechanisms of beta-HPV mediated carcinogenesis will be discussed.

HPV Carcinomas in Immunocompromised Patients.

Human papillomavirus (HPV) infection is the most common sexually transmitted disease worldwide and can result in pre-malignancies or overt malignancies of the skin and mucosal surfaces. HPV-related illnesses are an important personal and public health problem causing physical, mental, sexual and financial detriments. Moreover, this set of malignancies severely affects the immunosuppressed population, particularly HIV-positive patients and organ-transplant recipients. There is growing incidence of HPV-associated anogenital malignancies as well as a decrease in the average age of affected patients, likely related to the rising number of high-risk individuals. Squamous cell carcinoma is the most common type of HPV-related malignancy. Current treatment options for HPV infection and subsequent disease manifestations include imiquimod, retinoids, intralesional bleomycin, and cidofovir; however, primary prevention with HPV vaccination remains the most effective strategy. This review will discuss anogenital lesions in immunocompromised patients, cutaneous warts at nongenital sites, the association of HPV with skin cancer in immunocompromised patients, warts and carcinomas in organ-transplant patients, HIV-positive patients with HPV infections, and the management of cutaneous disease in the immunocompromised patient.

Blistering Distal Dactylitis in an Adult.

BACKGROUND: Blistering distal dactylitis is a localised infection of the anterior pad of the distal phalanx of the digits. It most commonly affects children and uncommonly adults with a history of immunosuppression or trauma. OBJECTIVE: A case of blistering distal dactylitis in a 32-year-old male is reported. The patient was not immunocompromised and did not report trauma. CONCLUSION: Blistering distal dactylitis may rarely present in adults (including those who are not immunocompromised or reporting trauma) and thus should be in the differential diagnosis for an adult presenting with bullae at the fingertips. The differential diagnosis for this presentation also includes herpetic whitlow, epidermolysis bullosa, bullous impetigo, and friction blisters.