Progression of undiagnosed cutaneous lymphoma after anti-tumor necrosis factor-alpha therapy.

BACKGROUND: Cutaneous lymphoma diagnosed after anti-tumor necrosis factor-α therapy (anti-TNF-α) has been reported in the literature, yet a clear link between both events remains elusive. OBJECTIVE: To review our experience with cutaneous lymphoma diagnosed during or after the use of anti-TNF-α therapies. METHODS: This is a multicenter retrospective study and a literature review. RESULTS: A total of 22 cases, including 20 cutaneous T-cell lymphomas (CTCLs) and 2 cutaneous B-cell lymphomas, were identified. In the CTCL group, 75% of the patients received an anti-TNF-α agent for a presumed inflammatory skin condition. Mycosis fungoides and Sézary syndrome were the most common subtypes of CTCL diagnosed. Advanced disease (stage IIB to IVA) was commonly seen at time of diagnosis and required aggressive therapy, including stem cell transplant in 3 patients; 2 patients in whom cutaneous B-cell lymphomas was diagnosed had an indolent course. A total of 31 cases were gathered from a literature search. LIMITATIONS: This is a retrospective study. CONCLUSIONS: Our findings suggest that the disease of most of the identified patients was misdiagnosed as psoriasis or eczema; therefore, a comprehensive morphologic and molecular review of skin biopsy specimens and peripheral blood samples should be considered before initiation of anti-TNF-α therapy in patients with poorly defined dermatitis or atypical presentations of psoriasis.

Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium, or androgenic alopecia.

BACKGROUND: Hair loss may significantly impact an individual's self-image, and studies indicate that patients with both clinically apparent and clinically imperceptible hair loss may have significantly decreased quality of life (QoL). Moreover, clinical severity of hair loss does not necessarily predict impact on QoL. OBJECTIVE: The aim of this study was to assess QoL in patients (n = 104) with alopecia areata, telogen effluvium, and androgenic alopecia, and to compare QoL with hair loss severity (HLS) as independently rated by both patient and dermatologist. METHODS: Questionnaires and clinical assessment tools were used to assess HLS, and QoL was measured by completion of Skindex-16. RESULTS: Overall, patients rated their hair loss as more severe than the dermatologist, and the patient's HLS rating more strongly correlated with QoL than the dermatologist's rating. Clinical assessment of HLS did not reliably predict the patient's QoL, nor did it predict the patient's perception of HLS. LIMITATIONS: A convenience sample was recruited from a referral clinic and Skindex-16 has not been validated for use in women's alopecia disorders. CONCLUSION: These findings indicate dermatologists should address these psychosocial and QoL issues when treating patients with alopecia.

Skin care and cosmeceuticals: Attitudes and trends among trainees and educators.

INTRODUCTION: Patients often seek skin care recommendations from their dermatologist. The objective of this study was to determine the degree of education dermatology residents receive on skin care and cosmeceutical products, the source of education, and the attitude of trainees and their educators toward skin care and cosmeceuticals. METHODS: A cross-sectional survey of dermatology residents and faculty via an online survey administered June 2015 and August 2015, respectively. RESULTS: In total, 104 dermatology residents and 50 dermatology faculty members completed the survey. Among the dermatology residents and faculty, equal distribution was represented across the country. The majority of residents and faculty (62% and 69%, respectively) report discussing skin care with up to 25% of their patients. Among resident participants, 76.5% "agree or strongly agree" that skin care and cosmeceutical education should be part of their education and the majority of residents (74.5%) report their education has been "too little or nonexistent" during residency. In contrast, the majority of the faculty (60%) reports their resident education is "just the right amount or too much" (P < .001). CONCLUSIONS: Skin care and cosmeceutical recommendations are often discussed in dermatology visits. Dermatology residents feel that education on these products should be a part of their residency training.

Thinking about CNS metastasis in cutaneous lymphoma: Analysis of existing data.

To determine some of the key clinical features that help prompt clinicians to pursue additional work-up for evaluation of CNS involvement of MF, we conducted a systematic review to better define characteristics, treatments, outcomes, and mortality in these patients. Our analyses indicated that neurologic surveillance after the diagnosis of MF is crucial. Review of systems should include change in mentation, vestibular, and ocular symptoms. Progression to CNS involvement does not always occur in tandem with cutaneous disease burden. Single-agent therapies can delay disease progression and improve prognosis. Multi-agent treatment does not improve survival.

Brentuximab vedotin in CD30+ primary cutaneous T-cell lymphomas: a review and analysis of existing data.

BACKGROUND: The utility of brentuximab vedotin (BV) in CD30+ systemic lymphomas is established, however evidence for treating primary cutaneous lymphoma remains limited. This study aimed to evaluate BV in treating CD30+ transformed mycosis fungoides (MF) and primary cutaneous anaplastic large cell lymphoma (PC-ALCL). METHODS: A literature review was conducted, and we analyzed data from published trials and case reports obtained via search of Ovid-MEDLINE® and PubMed databases. The search yielded 372 reports, and 10 publications met inclusion criteria. Sixty-one patients with CD30+ transformed MF and seven with PC-ALCL were included. RESULTS: Mean age at BV initiation was 60.8 years (67 - PC-ALCL; 60.1 - MF), and 4.1 therapies were attempted prior to BV (3.1 - PC-ALCL; 4.2 - MF). The overall response rate was 67.7% (100% - PC-ALCL; 63.9% - MF), with 16.2% of patients experiencing complete response (100% - PC-ALCL; 6.6% - MF). Mean time to clinical response was 5.3 and 9.3 weeks for PC-ALCL and MF, respectively. Mean response duration for patients with PC-ALCL was 7.6 and 7.8 months for MF. Peripheral neuropathy (57.2%) and fatigue (35.6%) were the most commonly reported adverse effects. CONCLUSIONS: This analysis summates the current evidence regarding the use of BV in treating CD30+ MF and PC-ALCL. Preliminary results indicate that BV is effective for CD30+ CTCL, however additional studies with larger sample sizes are necessary. The study provides clinicians with the clinical context in which BV may be appropriate as well as information regarding therapeutic expectations and outcomes.

CD30+ Primary Cutaneous Post-transplant Lymphoproliferative Disorder with Signet-ring Cell Features.

We report a case of primary cutaneous CD30+ post-transplant lymphoproliferative disorder with an uncommon finding of signet ring cell features in a heart transplant patient. The neoplastic cells were CD4 and CD30 positive, and negative for S-100, pancytokeratin, myeloperoxidase, and CD56. In situ hybridization for Epstein Barr Virus (EBV) was negative, even though the patient did have EBV viremia.

Integration of Dermatology-Focused Physical Diagnosis Rounds and Case-Based Learning within the Internal Medicine Medical Student Clerkship.

BACKGROUND: Over half of dermatologic conditions are seen by nondermatologists, yet medical students receive little dermatology education. Medical students in the clinical years of training at our institution felt insecure in their physical diagnosis skills for dermatologic conditions. OBJECTIVE: The objective of this study was to implement dermatology-focused curricula within the Internal Medicine (IM) Core Clerkship to increase student confidence in diagnosing skin diseases. METHODS: Two dermatology-focused sessions were integrated into the IM Clerkship. A faculty dermatologist leads students on a dermatology-focused physical diagnosis "Skin Rounds", where patients are seen at the bedside and students practice describing skin lesions and forming a differential diagnosis. Students also participate in a case-based active learning session. A dermatologist selects images of common skin conditions that students describe utilizing appropriate terminology and offer a differential diagnosis. The impact of these sessions was assessed through survey-based student feedback and by comparing the results from the IM Shelf Exam before and after intervention. RESULTS: A total of 74 students completed the skin rounds survey (32% response rate). About 99% (n = 73) of students felt that skin rounds were effective and useful, and 92% (n = 68) of students reported that they felt more confident in describing skin lesions afterward. A total of 43 students completed the case-based learning session survey (37% response rate), and 98% (n = 42) of students strongly agreed or agreed that the session was effective and useful. Performance on the dermatologic questions of the IM Shelf Exam was analyzed. While not statistically significant at P < 0.05, students improved from an average of 77% correct responses before intervention to 79% afterward (P = 0.60). CONCLUSIONS: Our case-based and bedside teaching interventions were met with high satisfaction from medical students and increased their confidence in describing skin lesions. This intervention can serve as a model to improve dermatology education and can be adapted to utilize the IM clerkship to address curriculum inadequacies at other institutions.