In-Transit Metastasis From Squamous Cell Carcinoma.

BACKGROUND: In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients. OBJECTIVE: To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis. METHODS AND MATERIALS: A multicenter case series treated by Australian and New Zealand clinicians. RESULTS: In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively. CONCLUSION: In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.

Vulvovaginal pyoderma gangrenosum secondary to rituximab therapy.

Rituximab is being used increasingly for the treatment of B-cell malignancies and nonmalignant conditions. Pyoderma gangrenosum is a rare neutrophilic dermatosis, which can be either idiopathic or associated with underlying systemic inflammatory conditions. We present a series of 4 patients who presented with ulcerative pyoderma gangrenosum in the vulvovaginal area after treatment with rituximab.

Defining urticarial dermatitis: a subset of dermal hypersensitivity reaction pattern.

BACKGROUND: Urticarial dermatitis may represent a useful term for a subset of a reaction pattern designated most commonly as dermal hypersensitivity by pathologists. The term is not commonly used, and requires definition to determine whether it is clinically relevant. OBJECTIVES: To define urticarial dermatitis and distinguish it from other urticarial reaction patterns and to review the frequency with which dermatologists can recognize clinical settings that match the biopsy findings of urticarial dermatitis. DESIGN: Retrospective analysis of clinical and/or histological diagnosis of urticarial dermatitis, applying strict histological criteria in a center using urticarial dermatitis as a diagnostic term in 190 archived reports. SETTING: Tertiary referral dermatopathology service reporting for dermatological practices in Sydney, Australia. MAIN OUTCOME MEASURES: The correlation between clinical and histological diagnoses of urticarial dermatitis and alternate diagnoses was analyzed. The frequency of positive immunofluorescence findings for bullous pemphigoid was determined in a subset of patients with urticarial dermatitis in whom this test was ordered to exclude prodromal bullous pemphigoid. RESULTS: Urticarial dermatitis was the histological diagnosis in at least 1 biopsy result in 148 patients, and matched the provisional clinical diagnosis in 49 (33.1%) patients. Urticarial dermatitis was the only diagnosis provided in 21 patients. The main alternate clinical diagnoses provided were early bullous pemphigoid or dermatitis herpetiformis (47 patients [31.8%]), dermatitis (39 patients [26.4%]), drug reaction (35 patients [23.6%]), urticarial vasculitis (24 patients [16.2%]), and urticaria (12 patients [8.1%]). In 91 patients with a clinical diagnosis of urticarial dermatitis, the histological diagnosis in at least 1 biopsy result was matched in 49 patients (53.8%); other histological diagnoses included dermatitis (21 patients [23.1%]), papular urticaria (12 patients [13.2%]), drug reaction (6 patients [6.6%]), and urticaria (3 patients [3.3%]). Review of 38 direct immunofluorescent results for prodromal bullous pemphigoid and a biopsy finding of urticarial dermatitis revealed only 3 positive results (7.9%). CONCLUSIONS: Urticarial dermatitis seems to be a useful histological and clinical term for a subset of the dermal hypersensitivity reaction pattern. Although the clinical presentation is not restricted to a specific entity, eczema and drug reactions seem to be the most frequent clinical associations; and in a subset of patients, urticarial dermatitis remains as a recognizable reaction pattern. Urticarial dermatitis without eosinophilic spongiosis is not a reliable indicator for bullous pemphigoid, because the findings of immunofluorescence are often negative.

Rituximab causing deep ulcerative suppurative vaginitis/pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a rare cause of purulent vulvovaginal ulceration. Six recent cases of vulvovaginal pyoderma gangrenosum associated with rituximab are described. All cases were seen in the setting of rituximab used for the treatment of B cell non Hodgkin's lymphoma (NHL). Age range was 50-74; symptoms were present for 2-24 months and severe pain, heavy discharge and large, deep purulent ulcers extending into the vagina were seen. This article reviews previous reports of vulvovaginal pyoderma gangrenosum, discusses important differential diagnoses in this setting, and provides evidence supporting rituximab as the cause of pyoderma gangrenosum in this cohort.

An analysis of the dermatological uses of mycophenolate mofetil in a tertiary hospital.

BACKGROUND: Mycophenolate mofetil (MMF) is increasingly being used by dermatologists to treat various skin conditions, but limited evidence exists regarding its efficacy. OBJECTIVE: To evaluate safety and efficacy of MMF in the treatment of dermatological conditions. METHODS: A retrospective chart review of all the dermatology patients treated with MMF between October 1999 and July 2008 at a university-based teaching hospital in Australia. RESULTS: Sixty-nine patients included 43 females (62%) and 26 males. Nineteen patients (27%) achieved complete remission (CR) and 14 (20%) had no response to therapy. The average duration of treatment was 18.4 months and the mean daily dose was 2 g. Thirty-two patients (47%) experienced side effects, though most were mild. Factors influencing response to MMF were studied, and older age (p=0.005), diagnosis (p=0.008) and duration of treatment (p=0.02) were found significant. In a multivariate analysis, only the diagnosis remained statistically significant. There was a differential response to MMF between the various dermatological disorders studied. Complete response was achieved in 56%, 53% and 46% of the patients with atopic dermatitis (AD), immunobullous disorders and neutrophilic dermatoses, respectively, while none of the patients with psoriasis achieved CR. CONCLUSION: Our study shows that MMF is more effective in AD and immunobullous disorders than in psoriasis and pyoderma gangrenosum.