Multiple Dorsal Hand Actinic Keratoses and Squamous Cell Carcinomas: A Unique Presentation following Extensive UV Nail Lamp Use.

Squamous cell carcinoma (SCC) is the second most common skin cancer worldwide, and exposure to ultraviolet (UV) light is a major cause of SCC. UV nail lamps can be used for drying and hardening acrylic or gel nail polish. We report a case of a 52-year-old Caucasian woman with an 18-year history of UV nail lamp use every 3 weeks and an 18-year history of weekly tanning bed use who presented with over 25 actinic keratoses and two SCC in situ on her dorsal hands. Of note, this patient has never had any previous biopsies, skin cancer or precancers, or skin cancer or precancer treatment at any time in the past and on skin examination had no precancers or cancers elsewhere on her body. We also review the existing research regarding nail lamp use, which overall suggests that the risk of carcinogenesis is low, and discuss ways dermatologists can educate patients regarding proper UV nail lamp use to minimize risks. This patient's extensive UV nail lamp use coupled with UVA exposure from tanning beds may have put her at particular risk and exacerbated the effects of the nail lamp alone.

Atypical Mycobacterial Infection Arising Amid Corticosteroid Therapy for Livedoid Vasculopathy.

Patients who suffer from rare skin diseases may try numerous therapies with many potential side effects before achieving remission. Livedoid vasculopathy (LV) is one such rare disease that lacks a definitive treatment as evidenced by randomized controlled trials. Although corticosteroids help reduce the pain flares associated with LV, they come at the risk of immunosuppression. We present a case of disseminated cutaneous infection of M. chelonae/abscessus arising in a diabetic patient on long-term corticosteroid therapy. This patient required an intensive antibiotic regimen and potentially lifelong antibiotic suppression pending improvement of her disseminated cutaneous infection. We report this case to increase awareness of the diagnostic consideration of atypical, rapidly growing mycobacterial (RGM) infection when encountering patients with a diffuse onset of ulcerative skin nodules amid a background of diabetes and long-term corticosteroid use.

Repigmentation of Tenacious Vitiligo on Apremilast.

Vitiligo is a common pigment disorder characterized by acquired loss of function or absence of melanocytes, leading to distinct areas of depigmentation. Physical exam reveals sharply demarcated, depigmented macules or patches on otherwise normal skin. Vitiligo can present at any age, in any skin color. There is no specific serologic marker for diagnosis, but patients often have other autoimmune problems. Treatment options are limited and are difficult given the fact that the pathogenesis of the disease is not well elucidated. We present the case of a 52-year-old woman with vitiligo for over 2 decades. The patient's medical history reveals a lack of response to many different approaches. This case highlights the ability of apremilast, an FDA-approved drug for the treatment of psoriasis and psoriatic arthritis, to achieve repigmentation in a case a vitiligo that has been extremely recalcitrant.

Perniosis (chilblains) masquerading as CA-MRSA: a case report.

Perniosis (chilblains) is a vasospastic, inflammatory disease that occurs when the skin is subjected to cold above the freezing point, under damp conditions. Erythematous (violaceous) blisters, ulcerations or pustules that sit on an edematous base, accompanied by pain, burning or itching, are usually evident. To the inexperienced clinician it may resemble community-associated methicillin-resistant Staphylococcus aureus and could lead to inappropriate treatment. Here we report such a case.

Basal cell carcinoma with matrical differentiation in a transplant patient: a case report and review of the literature.

BACKGROUND: Shadow cells, characterized by basaloid squamous cells with a distinct well-defined border and a central unstained area as a shadow of lost nuclei, are characteristic of pilomatricoma, a distinct neoplasm of hair matrix differentiation. The presence of shadow cells within tumor islands composed of follicular germinative cells of an otherwise classic basal cell carcinoma (BCC) has been considered as a distinct diagnostic category of BCC with matrical differentiation. We present a case of BCC with matrical differentiation in a transplant patient. To our knowledge, only 10 cases [Aloi et al. Am J Dermatopathol 1988; 10: 509; Ambrojo et al. Am J Dermatopathol 1992; 14: 293; Sagol et al. East J Med 1999; 4: 37; Kwittken J. Cutis 2002; 69: 57; Kim et al. Yonsei Med J 2003; 44: 523] of BCC showing matrical differentiation have been reported. None have been reported arising on the background of immunosuppression. METHODS: A 58-year-old male cardiac transplant patient with a nodule on the dorsum of left hand was studied. It arose and enlarged rapidly within a few months, causing irritation and bleeding. The nodule was surgically excised and submitted for histopathologic evaluation. The sections were prepared by hematoxylin and eosin (H&E) method. RESULTS: The H&E-stained sections of the hand lesion revealed multiple nodular masses of basaloid follicular germinative cells. In some areas, there was peripheral palisading and stromal retraction artifact typical of classic BCC. In these areas, the tumor nodules were connected to the epidermis, whereas in others, it extended deep into the reticular dermis to the subcutaneous fat junction. Elsewhere, the majority of the tumor contained a population of shadow cells, similar to those in pilomatricoma, with basaloid-appearing matrical cells in the periphery. Trichohyaline granules were identified in the cytoplasm of many of the peripheral basaloid cells. These granules are one of the characteristic features of follicular matrix differentiation. Mitoses were rare. Areas of cystic degeneration were present throughout the tumor. There was no evidence of an infiltrating growth pattern, lymphovascular invasion, or sarcomatoid growth pattern. CONCLUSION: BCC with matrical differentiation is a distinct pathologic entity and a rare subtype of BCC featuring shadow and matrical cells, typically seen in pilomatricoma, a benign hair matrix neoplasm. This tumor has not yet been reported in an immunosuppressed transplant patient.

Assessment of etiologic agents in acne pathogenesis.

Acne is a chronic inflammatory disease of the pilosebaceous units. Traditional etiologic factors include increased sebum production, ductal hyperkeratosis, abnormality of the microbial flora within the pilosebaceous unit, and mediators of inflammation. Recent developments do not refute these familial elements, but rather refine particular aspects. Interleukin-1a influences hypercornification of the infundibulum as well as the inflammatory response by inducing the production of vascular endothelial growth factor in dermal papilla cells and follicular keratinocytes of the pilosebaceous unit. New retinoids have been developed based on controlling cellular proliferation and differentiation in the pilosebaceous unit by their action on nuclear receptors of cells. Dermal inflammation is not due to presence of bacteria, but from biologically active mediators produced by Propionibacterium acnes. The environment within the pilosebaceous unit is probably more important than the absolute number of P. acnes organisms. Indeed, the major role of the sebaceous gland appears to be supplying P. acnes needed nutrients. Moreover, the microbiologic principle of biofilms appears to be applicable to P. acnes in acne.

Tinea corporis in human immunodeficiency virus-positive patients: case report and assessment of oral therapy.

UNLABELLED: Dermatophytosis in immunocompromised hosts is more varied and often more severe than in immunocompetent hosts. Early recognition and treatment with systemic therapy are important in human immunodeficiency virus (HIV)-positive patients in order to prevent severe infection. Potential drug resistance can occur due to chronic usage of systemic azole therapy in such patients, or the existence of atypical fungi. Although warnings have been made of possible drug interactions between certain antifungals and antiretroviral medications, only one combination has shown a clinically significant interaction. A case treated aggressively with oral terbinafine at the onset is presented. BACKGROUND: Dermatophytosis in immunocompromised hosts is more varied and often more severe than in immunocompetent hosts. Early recognition and treatment with systemic therapy are important in human immunodeficiency virus (HIV)-positive patients in order to prevent severe infection. OBJECTIVE: To analyze potential therapies for dermatophyte infections in immunocompromised patients and risk of drug resistance and interactions with antiretroviral medications. METHODS: Literature search based on MEDLINE (1966-March 2003) and additional references obtained from cross-referencing retrieved articles. All information deemed relevant by the reviewers was included. A case study was employed to exemplify the usage of this information in patient care. RESULTS: Although warnings have been made of possible drug interactions between certain antifungals and antiretroviral medications, only one combination has shown a clinically significant interaction. CONCLUSIONS: When considering drug interactions and side-effects, there are no clinically significant reasons to avoid any oral antifungal for dermatophytosis in the HIV-positive patient.

Migraine is associated with livedo reticularis: a prospective study.

OBJECTIVE: To investigate the relationship of livedo reticularis, an ischemic dermatopathy, and migraine, an ischemic stroke risk factor. BACKGROUND: Livedo reticularis refers to the reddish-blue reticular mottling of the skin resulting from narrowing of small and medium arteries at the dermis-subcutis border. A subset of patients with livedo reticularis develop stroke in the absence of other vascular risk factors, which has been termed Sneddon syndrome. We undertook this prospective study in a non-neurology clinic to delineate further the relationship of livedo reticularis and migraine. METHODS: Patients in a general dermatology clinic were interviewed for vascular risk factors and history of migraine in accordance with the International Headache Society (IHS) criteria. A dermatologist, not familiar with the interview, recorded the primary dermatological diagnosis and the presence or absence of livedo reticularis on examination. RESULTS: Two hundred eighty-one consecutive patients (184 women and 97 men; average age, 52 years) were interviewed and examined. Seventy-five (27%) had migraine (IHS codes 1.1, 1.2) and an additional 18 (6%) had atypical migraine (IHS 1.7). Livedo reticularis was noted in 46 patients (16%), with the frequency higher in women than men (42 [23%] of 184 versus 4 [4%] of 97; P <.0001). The frequency of livedo reticularis in patients with migraine was higher than in those without migraine (24 [26%] of 93 versus 22 [12%] of 188; P =.002), and higher in female than male migraineurs (23 [32%] of 72 versus 1 [5%] of 21; P =.012). In logistic regression analysis of the women, migraine was associated with livedo reticularis (odds ratio [OR], 2.3; confidence interval [CI], 1.08 to 4.71), as well as with stroke (OR, 4.0; CI, 0.87 to 18.21), coronary artery disease (OR, 3.5; CI, 1.16 to 10.33), and deep venous thrombosis (OR, 3.2; CI, 0.98 to 10.32). CONCLUSIONS: In women, migraine is associated with stroke, coronary artery disease, deep venous thrombosis, as well as livedo reticularis, a dermatopathy which has been pathologically linked to cerebral vasculopathy. Whether migraineurs with livedo reticularis compose a subset at higher risk of thrombosis, including stroke, deserves further investigation.