Neutrophilic dermatosis complicating lenalidomide therapy.

Lenalidomide, a derivative of thalidomide, is an immunomodulatory agent introduced in 2004 for the treatment of multiple myeloma in combination with dexamethasone. It is also indicated for the treatment of myelodysplastic syndrome and is currently under investigative use for metastatic melanoma. We present a case of neutrophilic dermatosis involving predominantly the lower extremities in a patient receiving lenalidomide therapy for multiple myeloma.

Bexarotene treatment of late-stage mycosis fungoides and Sézary syndrome: development of extracutaneous lymphoma in 6 patients.

Bexarotene is a retinoid drug that is approved for the treatment of cutaneous T-cell lymphoma. We report 6 cases in which the initiation of bexarotene therapy for cutaneous T-cell lymphoma was temporally associated with the progression of internal disease despite improvement in cutaneous signs and symptoms. It is possible that bexarotene contributed to this progression. Although bexarotene therapy may alleviate symptoms and signs of cutaneous T-cell lymphoma, careful surveillance of lymph nodes and solid organs during treatment is advised.

The contact allergen replacement database and treatment of allergic contact dermatitis.

OBJECTIVE: To determine whether the Contact Allergen Replacement Database would improve clinical outcomes for patients with allergic contact dermatitis associated with topical skin care products by helping patients avoid known allergens. DESIGN: This study was a randomized, single-blind, controlled trial. SETTING: The study was conducted at the outpatient facilities at Mayo Clinic, Scottsdale, Ariz, and Rochester, Minn. PARTICIPANTS: Of the 29 patients enrolled, 21 completed the study. INTERVENTION: All patients were randomly assigned to either a Contact Allergen Replacement Database group or a traditional therapy group. Patients in the database group received an individualized list of topical skin care products free of the antigens identified by the results of their individual patch tests. Otherwise, the 2 groups received identical therapy. MAIN OUTCOME MEASURES: To evaluate erythema, scale, and pruritus at 3-month follow-up, each variable was given a severity score from 0 to 3. A 1-point change was considered clinically notable. We also evaluated total physician-patient counseling time and patient satisfaction. RESULTS: We found no statistically significant differences (P>.05) between the 2 treatment groups on measures of disease activity and counseling time. However, 91% of the database group reported the allergen-free product list to be either somewhat helpful or very helpful in managing contact dermatitis. All the patients without access to the database said it would have been helpful. CONCLUSIONS: Although this small study, with its limited follow-up, did not yield objective evidence supporting the use of the Contact Allergen Replacement Database, the database-generated product lists were favorably received by patients. We anticipate an expanded clinical role for this database as an Internet-based resource.

Perioral lesions and dermatoses.

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.

Acne fulminans.

Acne fulminans is a syndrome of fulminant, necrotizing acne associated with bone lesions, constitutional symptoms, and laboratory abnormalities. A case report of an adolescent male with acne fulminans following withdrawal of isotretinoin and prednisone is presented.

Cryptococcal infection in sarcoidosis.

A 48-year-old man with a history of sarcoidosis was transferred to the Mayo Clinic for evaluation and management of progressive neurologic decline. Two years before admission, he was admitted to a local hospital with mental status changes accompanied by ataxia and severe headache. A diagnosis of pulmonary and central nervous system sarcoidosis was made based on computed tomography of the head, lumbar puncture, and chest radiography. A mediastinoscopy with lymph node biopsy exhibited noncaseating granulomas and negative stains for microorganisms. Prednisone therapy was initiated at 80 mg/day. Clinical improvement was apparent for 13 months during steroid therapy until the slow taper reached a dosage of 20 mg/day. At that time, the patient was readmitted to the local hospital with severe confusion and skin lesions. When intravenous methylprednisolone therapy for presumed central nervous system sarcoidosis did not improve the patient's mental status, he was transferred to the Mayo Clinic. Physical examination of the thighs revealed large, well-marginated, indurated, irregularly bordered, violaceous plaques and rare, umbilicated, satellite papules with central hemorrhagic crusts (Fig. 1A). Superficially ulcerated plaques with a similar appearance to the thigh lesions were coalescing around the lower legs (Fig. 1B). A skin biopsy specimen of the thigh demonstrated abundant numbers of encapsulated organisms and minimal inflammatory response (Fig. 2). Skin, blood, and cerebrospinal fluid cultures confirmed the presence of Cryptococcus neoformans. Amphotericin and flucytosine combination therapy was initiated, and steroid dosages were gradually tapered. A test for human immunodeficiency virus was negative. The patient was dismissed from hospital after a complicated 2-month course resulting in improved mental status but progression of the lower extremity ulcerations as a result of polymicrobial infection.

Disseminated gonococcemia.

A 26-year-old woman presented with a high-grade fever and chills of 2 days' duration. She complained of associated joint pain, especially in the wrists and knees. One day before admission, tender skin lesions began to develop on the fingers, and subsequently spread to the more proximal extremities. The patient recalled having a sore throat and a nonproductive cough before the onset of the fever and eruption. The past medical history was significant for Gardnerella vaginitis and several urinary tract infections. The patient was taking oral contraceptive pills; her most recent menstruation was 3 weeks before admission. She reported having sexual intercourse with her boyfriend 2 weeks before admission. The patient's temperature was 40 degrees C. Dermatologic examination revealed a 6-mm, hemorrhagic pustule on an ill-defined pink base, overlying the volar aspect of the left second proximal interphalangeal joint (Fig. 1a). Scattered on the upper and lower extremities were occasional round, ill-defined pink macules with central pinpoint vesiculation (Fig. 1b). A skin biopsy of the digit revealed a dense neutrophilic infiltrate with leukocytoclasis and marked fibrin deposition in the superficial and deep dermal vessels (Fig. 2a). Gram stains demonstrated the presence of Gram-negative diplococci (Fig. 2b). Laboratory findings included leukocytosis (leukocyte count of 20 x 109/L, with 81% neutrophils). Analysis of an endocervical specimen by polymerase chain reaction was positive for Neisseria gonorrhoeae and negative for Chlamydia trachomatis. Throat and blood cultures grew N. gonorrhoeae. Specimen cultures obtained by skin biopsy yielded no growth. Results of serologic analysis for human immunodeficiency virus, hepatitis, syphilis, and pregnancy were negative. Beginning on admission, intravenous ceftriaxone, 2 g, was administered every 24 h for 6 days, followed by oral cefixime, 400 mg twice daily for 4 days. Oral azithromycin, 1 g, was administered to treat possible coinfection with C. trachomatis. By treatment day 4, the patient was afebrile, with the resolution of leukocytosis and symptomatic improvement of arthralgias.

Ocular melanoma metastatic to skin: the value of HMB-45 staining.

BACKGROUND: Cutaneous metastatic disease is an important finding that may represent the first sign of systemic cancer, or, if already known, that may change tumor staging and thus dramatically altered therapeutic plans. Although cutaneous metastases are relatively frequent in patients with cutaneous melanoma, they are less so from ocular melanoma. OBJECTIVE: To demonstrate the value of HMB-45, staining in the detection of ocular melanoma metastatic to skin. METHODS: The immunohistochemical stain HMB-45 a monoclonal antibody directed against intact human melanoma cells, was employed on a skin biopsy specimen from a cutaneous tumor. RESULTS: HMB-45 staining was positive in the atypical hyperchromatic cells of the deep dermis. CONCLUSION: HMB-45 may be of value in the detection of ocular melanoma metastatic to skin. Cutaneous metastatic disease is a somewhat common and extremely important diagnosis. Although cutaneous metastases from cutaneous melanoma are relatively frequent, those from ocular melanomas are less so. Use of histochemical staining, especially the HMB-45 stain, allows confirmation of the diagnosis.