Bilateral Blistering Rash Following Gastric Bypass Procedure and Mushroom Soup Diet: Hepatitis C Virus-Seronegative Necrolytic Acral Erythema.

Necrolytic acral erythema (NAE) is an uncommon cutaneous disorder characterized by a symmetric acral distribution of erythematous plaques with underlying epidermal necrosis. While typically presenting in the context of hepatitis C virus (HCV) infection, NAE can also present secondary to nutritional deficiency or systemic disease. We present a case of NAE in a 66-year-old patient with no history of HCV infection status post gastric bypass who had a three-month history of eating only mushroom soup. The patient underwent a punch biopsy and was tested for a variety of nutritional deficiencies. Biopsy demonstrated partial necrosis of the upper epidermis, with subjacent re-epithelialization, squamatization, and vacuolopathy of the basal epidermis. He was treated with zinc replacement therapy after initial trials of tacrolimus and clobetasol were unsuccessful. At follow-up, he had significant improvement of the lesions. This case provides an example of an atypical presentation of NAE in the absence of HCV infection that presented as a complication of gastric bypass-associated nutritional deficiency.

The Successful Treatment of COVID-19-Induced Bullous Pemphigoid With Dupilumab.

Bullous pemphigoid (BP) is a rare autoimmune blistering condition that predominantly affects the elderly population. Typical treatment regimens target the immune system and inflammatory response. We present a case of BP in a 78-year-old male patient that occurred following the coronavirus disease 2019 (COVID-19) vaccination. This case was refractory to topical steroids and immunosuppressants. However, it responded to treatment with dupilumab, a monoclonal antibody therapy. Dupilumab is classically indicated for the treatment of asthma, eosinophilic esophagitis, atopic dermatitis, and chronic rhinosinusitis with nasal polyposis. We highlight the importance of considering the off-label use of dupilumab and its success in treating BP.

Assessing the Diagnostic Accuracy of Teledermatology Consultations at a Local Veterans Affairs Dermatology Clinic.

With the advances in health information technology and the need for increased access to specialized health care, the advent of telemedicine was designed to bring care to individuals at a distance. Telemedicine decreases barriers to health care and brings medical specialists to underserved areas and populations. We have seen a tremendous increase in the need and utilization of telemedicine during the COVID-19 pandemic due to the lockdowns and social distancing efforts. Virtual care continues to be extended to patients to maintain their health care needs when in-person clinic appointments are not feasible or ideal such as seen during a pandemic. Telemedicine is an additional tool that has proven vital to our healthcare system. To provide optimal care, a strong technological infrastructure must be in place. Once in practice, positive outcomes have been noted for patients and healthcare providers as diagnosis, treatment, and appropriate triage can be made virtually and at the patients' convenience. To ensure high-quality care is provided through the Veterans Affairs teledermatology consultation service, we investigated the concordance of teledermatology diagnoses with clinical examination findings through a retrospective chart review covering a one-year time period. Our study found a concordance of 75.3% between the teledermatology diagnoses and the in-person clinical diagnoses. The main limitation we found to virtual examination is the inability to perform total body skin examinations. We found that 60.2% of patients had additional diagnoses when examined in person, with 8.4% of patients having an additional malignant diagnosis. These findings highlight the need for in-person examinations when feasible to ensure that no other diagnoses go undiscovered if not captured on the submitted images for teledermatology consultation. Despite the limitations posed by photographic examination, teledermatology can be used as a reliable method for diagnosis when a conventional in-person examination is not readily available or ideal, such as during a pandemic, and can serve as a powerful triaging tool.

Discussing sentinel lymph node biopsy with your melanoma patients.

Sentinel lymph node biopsy, indicated for stage 1B/2 melanoma may be an underutilized diagnostic modality. Experts in the field agree that sentinel lymph node biopsy should be offered to patients with T1 melanomas with primary tumor ulceration, a mitotic rate greater than or equal to 1/mm2, and/or Clark level IV/V invasion especially if tumor thickness exceeds 0.75 mm. It is the responsibility of practitioners to characterize patients as eligible or non-eligible for the sentinel node procedure. Furthermore, it is important to obtain a fully informed consent and explain to patients the statistics of the progonostic information garnered by the test.

Case of fatal toxic epidermal necrolysis due to cardiac catheterization dye.

Cardiac catheterization is a very common procedure carried out for diagnostic as well as therapeutic reasons. Complications are not surprising due to the invasive nature of the procedure. Most of these complications have been seen numerous times by cardiologists who frequent the catheterization laboratory. Unfortunately, this patient experienced an extremely rare complication that ultimately resulted in his death. Here, the authors report a case of toxic epidermal necrolysis (TEN) resulting from the nonionic radiocontrast agent used in cardiac catheterization.

Merkel cell carcinoma: clinical characteristics, markers, staging and treatment.

Merkel cell carcinoma (MCC) is a highly aggressive neoplasm affecting primarily the elderly Caucasian population. Earlier detection of this neoplasm may achieve a better prognosis and an improved outcome. Here, the authors review the typical clinical features of MCC to serve as a reference tool for clinicians in determining when a biopsy may be warranted. An array of immunohistochemical markers may be utilized to differentiate MCC from other neuroendocrine tumors. The staging and concomitant treatment options of MCC are discussed. In addition, the authors review therapeutic advances for treatment of MCC utilizing an array of target proteins.

The role of phototherapy in cutaneous T-cell lymphoma.

Cutaneous T-cell lymphoma (CTCL) is a type of non-Hodgkin's lymphoma characterized by the malignant proliferation of T lymphocytes in the skin. Phototherapy has been proven an effective treatment modality for CTCL, in particular early stage disease (patch and plaque). Specifically, broadband ultraviolet B (BB-UVB), psoralen and ultraviolet A (PUVA), and more recently narrowband UVB (NB-UVB) are the skin-directed phototherapies typically utilized. Phototherapy poses the risk of sunburn, photoaging and photocarcinogenesis. Combination therapies with IFN-alpha, retinoids (acitretin and isotretinoin) and rexinoid (bexarotene) are adjunctive systemic therapies that facilitate enhanced therapeutic response and often allow for lower doses of phototherapy. Extracorporeal photopheresis (ECP) has also been shown to be effective in more advanced stage disease.

The role of maintenance phototherapy in cutaneous T-cell lymphoma.

Phototherapy is well-recognized as effective therapy in early stage cutaneous T-cell lymphoma (patch and plaque), often resulting in complete clearance of clinical disease and subsequent remission. Although not curable, long-term remission can often be attained utilizing maintenance phototherapy, consisting of a course of less frequent treatments over time. Herein, the authors review the literature regarding the role of maintenance phototherapy in cutaneous T-cell lymphoma (CTCL) and its success in prolonging clinical remission and disease-free survival in CTCL.

Pyoderma Gangrenosum following Pacemaker Implantation: A Case Report and Review of Literature.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by noninfectious, inflammatory, ulcerating lesions. Pathergy can be seen in these patients, whereby minor trauma or surgery can result in the development of PG ulcerations. Here, we present a case of PG following pacemaker implantation. A 76-year-old male with a history of rheumatoid arthritis presented to the cardiology team with symptomatic bradycardia. Indications for implantation were met, and the procedure was performed in a routine fashion. The patient returned to clinic for follow-up four days later, complaining of pain at the incision site, coupled with erythema and purulent drainage. Consultations with an infectious disease specialist and a dermatologist were requested, and the diagnosis of pyoderma gangrenosum was considered. The patient underwent device removal and received systemic corticosteroids at a dose of 1 mg/kg prednisone with complete lesion healing in 3 weeks. While being maintained on steroids, the patient underwent reimplantation of a new pacemaker on the contralateral side without complication and had a normal postoperative course. We present this case report, along with the review of literature, in order to highlight the multidisciplinary approach to management, which requires dermatologic treatment in order to achieve pacemaker success.

Aquagenic syringeal acrokeratoderma: report of a case with histologic findings.

Aquagenic syringeal acrokeratoderma is a rare acquired condition characterized by painful symmetric swelling and hypopigmentation of the palms and lateral fingers, which develops after brief exposure to water. Histopathologic examination suggests that an aberration in the eccrine sweat gland apparatus may be the underlying cause of this condition. The "hand-in-the-bucket sign," in which patients arrive in their physician's office with their hand in a bucket of water to more readily demonstrate their lesions, is such a common presentation that it almost can be regarded as pathognomonic. All 12 cases reported to date have been in young females. We report a case of aquagenic syringeal acrokeratoderma in a male with unique histologic findings.

Sentinel lymph node biopsy in melanoma: Facts and controversies.

Three decades after its introduction in the 1990s, the sentinel lymph node biopsy for patients with localized cutaneous melanoma is still the subject of great debate in dermatology. Many questions remain unanswered, and studies currently in progress may or may not bring us any closer to determining the truth about sentinel lymph node biopsy and melanoma. We discuss the effect of sentinel lymph node biopsy on overall survival, the clinical and therapeutic implications of sentinel lymph node biopsy, and the melanoma patients who might be candidates for sentinel lymph node biopsy.