Immunopathogenic Insights on Preferential Human Herpesvirus-6 Reactivation in Drug Rash With Eosinophilia and Systemic Symptoms: A Scoping Review.

INTRODUCTION: Human herpesvirus-6 (HHV-6) is a ubiquitous lymphotropic betaherpesvirus that can reactivate in drug rash with eosinophilia and systemic symptoms (DRESS). Despite recent publications advancing our understanding of HHV-6 in DRESS, the exact role of HHV-6 in disease pathogenesis remains unclear. METHODS: A scoping review with the PubMed query "(HHV 6 AND (drug OR DRESS OR DIHS)) OR (HHV6 AND (drug OR DRESS OR DIHS))" was conducted in accordance with PRISMA guidelines. Articles containing original data on at least one DRESS patient with HHV-6 testing were included. RESULTS: Our search returned a total of 373 publications, of which 89 met eligibility criteria. HHV-6 reactivation occurred in 63% of DRESS patients (n = 748), which was significantly more often than other herpesviruses. HHV-6 reactivation was associated with worse outcomes and greater severity in controlled studies. Case reports have demonstrated sometimes fatal HHV-6-related multi-organ involvement. Temporally, HHV-6 reactivation typically occurs 2 to 4 weeks after DRESS onset and has been linked to markers of immunologic signaling, such as OX40 (CD134), an HHV-6 entry receptor. Efficacy of antiviral or immunoglobulin treatment has only been demonstrated anecdotally, and steroid use may affect HHV-6 reactivation. CONCLUSION: HHV-6 is implicated in DRESS more than in any other dermatologic condition. It is still unclear whether HHV-6 reactivation is cause or consequence of DRESS dysregulation. Similar pathogenic mechanisms precipitated by HHV-6 in other contexts may be relevant in DRESS. Future randomized controlled studies to assess effects of viral suppression on clinical outcomes is needed.

Incisional biopsy critical in obtaining definitive diagnosis in a clinically challenging case.

Tissue-sparing biopsy techniques are frequently used in clinical practice but can result in misdiagnosis of large, clinically challenging lesions. We present a case of a 70-year-old man with hidradenocarcinoma of the left chin, a diagnosis that was delayed owing to repeated superficial biopsies that were negative for disease. Diagnosis was ultimately obtained via an incisional biopsy. We discuss the clinical features of hidradenocarcinoma and why this diagnosis can be easily missed with superficial biopsies. It is important that dermatologists consider incisional biopsies in the workup of clinically challenging lesions for which malignancy is considered.

Techniques for Optimizing Surgical Scars, Part 3: Erythema, Hyperpigmentation, and Hypopigmentation.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. Part 3 focuses on scar revision for erythema, hyperpigmentation, and hypopigmentation. Scar revision options for erythematous scars include moist exposed burn ointment (MEBO), onion extract, silicone, methyl aminolevulinate-photodynamic therapy (MAL-PDT), pulsed dye laser, intense pulsed light (IPL), and nonablative fractional lasers. Hyperpigmented scars may be treated with tyrosinase inhibitors, IPL, and nonablative fractional lasers. Hypopigmented scars may be treated with needle dermabrasion, medical tattoos, autologous cell transplantation, prostaglandin analogues, retinoids, calcineurin inhibitors, excimer laser, and nonablative fractional lasers.

Firm, hyperpigmented subcutaneous nodule in the inguinal fold of an infant.

Subcutaneous juvenile xanthogranuloma (JXG) of the inguinal fold, an unusual location, was diagnosed in an infant. Subcutaneous JXG should be included in the differential diagnosis of subcutaneous nodules of the lower body, despite the absence of the characteristic yellowish hue usually associated with JXG.

Techniques for Optimizing Surgical Scars, Part 1: Wound Healing and Depressed/Atrophic Scars.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. In part 1, an overview of the importance of preoperative planning, intraoperative technique, and pathophysiology of wound healing is followed by a discussion of scar revision options for depressed/atrophic scars. Scar revision options for these scars include dermabrasion, needling and subcision, punch excision and grafts, fillers, nonablative fractional lasers, ablative and fractional ablative lasers, and platelet-rich plasma (PRP). This review examines the scar revision outcomes for each technique, discusses potential adverse effects, and highlights the importance of further studies to optimize postsurgical scar revision.

Techniques for Optimizing Surgical Scars, Part 2: Hypertrophic Scars and Keloids.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. Part 2 focuses on scar revision for hypertrophic and keloids scars. Scar revision options for hypertrophic and keloid scars include corticosteroids, bleomycin, fluorouracil, verapamil, avotermin, hydrogel scaffold, nonablative fractional lasers, ablative and fractional ablative lasers, pulsed dye laser (PDL), flurandrenolide tape, imiquimod, onion extract, silicone, and scar massage.