Keratoacanthomatous Changes: Unifying the Histologic Spectrum of Actinic Granuloma.

Actinic granuloma (AG) manifests as annular plaques on sun-damaged skin. There remains no universal consensus on the nosology, etiology, or clinicopathologic criteria of AG as a distinct entity. Broadly, AG is characterized by granulomatous inflammation, multinucleated giant cells, elastophagocytosis, and the absence of mucin and necrobiosis. It is not uncommon, however, to encounter overlapping histological features of other granulomas, such as granuloma annulare and necrobiosis lipoidica, confounding the diagnosis of this controversial entity. Herein, we describe 2 cases of AG with features of granuloma annulare and necrobiosis lipoidica, supporting the concept of AG as a histologic spectrum. These 2 cases displayed dilated follicular infundibula and pseudoepitheliomatous hyperplasia analogous to changes in keratoacanthomas. These unique epithelial changes, in tandem with characteristic elastin alterations and clinical findings, are helpful and unifying features that permit accurate diagnosis of this controversial entity.

Indurated Plaque with Bullae Formation on the Left Arm.

A 72-year-old white man presented to the clinic with a tender, pruritic lesion on the upper part of his left arm that had progressively worsened over 4 months. Physical examination revealed an erythematous to violaceous, indurated, and sclerotic plaque with multiple foci of crusting and erosions (Figure 1). The patient denied any recent trauma, travel, fever, chills, weight loss, or constitutional symptoms. Before presentation, he had undergone treatment with cephalexin, prednisone, and doxycycline without reported improvement. Laboratory studies were negative for antinuclear antibody and SCL70 antibody; however, an absolute eosinophilia of 1478/uL was noted.

Pseudoxanthoma elasticum-like changes in nonuremic calciphylaxis: Case series and brief review of a helpful diagnostic clue.

Calciphylaxis is a rare syndrome of vascular calcification with thrombosis that occurs most often in patients with end-stage renal disease, and it frequently portends a guarded prognosis. Rarely, nonuremic calciphylaxis (NUC) may occur; in this context, a strongly supportive histology is crucial in establishing the diagnosis. Herein, we describe 2 cases of NUC associated with pseudoxanthoma elasticum-like changes, identified in both initial nondiagnostic and subsequent diagnostic biopsy specimens. This unusual but helpful histologic finding may support the early diagnosis and treatment of a potentially life-threatening disease in the context of subtle histopathologic vascular changes or in the absence of classic clinical or laboratory findings.

Resident Rounds Part III: Case Report: Metastatic Cutaneous Squamous Cell Carcinoma in an African American Female.

Cutaneous squamous cell carcinoma (cSCC) is the most common skin cancer diagnosed in African Americans.1 Twenty to forty percent of cSCCs reported in African Americans are related to chronic scarring processes or areas of in ammation.2 Risk factors for developing cSCCs in patients of color include chronic scars resulting from burns, skin ulcers, and radiation sites; and chronic inflammatory diseases such as discoid lupus and hidradenitis suppuritiva.1 Although skin cancer only accounts for 1% to 2% of cancers diagnosed within African Americans, it is associated with increased morbidity and mortality in this population.1,3 Significant delays in diagnosis and treatment are largely thought to be responsible for this prognostic incongruity. The rate of metastasis in patients of color is 31%, compared with only 4% in Caucasians.4,5 Early recognition by physicians and increased awareness resulting in preventative measures by patients may decrease this noted disparity. J Drugs Dermatol. 2016;16(1):81-84..

Is a Wider Margin (2 cm vs. 1 cm) for a 1.01-2.0 mm Melanoma Necessary?

BACKGROUND: The current NCCN recommendation for resection margins in patients with melanomas between 1.01 and 2 mm deep is a 1-2 cm radial margin. We sought to determine whether margin width had an impact on local recurrence (LR), disease-specific survival (DSS), and type of wound closure. METHODS: Melanomas measuring 1.01-2.0 mm were evaluated at a single institution between 2008 and 2013. All patients had a 1 or 2 cm margin. RESULTS: We identified 965 patients who had a 1 cm (n = 302, 31.3 %) or 2 cm margin (n = 663, 68.7 %). Median age was 64 years, and 592 (61.3 %) were male; 32.5 and 48.7 % of head and neck and extremity patients had a 1 cm margin versus 18.9 % of trunk patients (p < 0.001). LR was 2.0 and  2.1 % for a 1 and 2 cm margin, respectively (p = not significant). Five-year DSS was 87 % for a 1 cm margin and 85 % for a 2 cm margin (p = not significant). Breslow thickness, melanoma on the head and neck, lymphovascular invasion, and sentinel lymph node biopsy (SLNB) status significantly predicted LR on univariate analysis; however, only location and SLNB status were associated with LR on multivariate analysis. Margin width was not significant for LR or DSS. Wider margins were associated with more frequent graft or flap use only on the head and neck (p = 0.025). CONCLUSIONS: Our data show that selectively using a narrower margin of 1 cm did not increase the risk of LR or decrease DSS. Avoiding a 2 cm margin may decrease the need for graft/flap use on the head and neck.

Dermal melanoma: A report on prognosis, outcomes, and the utility of sentinel lymph node biopsy.

INTRODUCTION: Historically dermal melanoma (DM) has been labeled as either stage IIIB (in-transit) or stage IV (M1a) disease. We sought to investigate the natural history of DM and the utility and prognostic significance of sentinel lymph node biopsy (SLNB). METHODS: Patients with DM undergoing SLNB at a single center from 1998 to 2009 were identified. RESULTS: Eighty-three patients met criteria, 10 (12%) patients had a positive SLNB. Of those, 5 (50%) recurred (all with distant disease). Twenty-one (29%) of the 73 SLNB negative patients recurred and of those, 15 (71%) developed distant metastases, whereas 6 (29%) developed local or regional recurrence, including two false-negative regional nodal recurrences. No in-transit recurrences were recorded. Five-year recurrence-free and disease-specific survival was significantly better for patients with a negative SLNB versus positive SLNB (56.8% vs. 22.2% P = 0.02, 81.1% vs. 61.0%, P = 0.05, respectively). CONCLUSION: SLNB has prognostic significance for RFS and DSS, and should be utilized in the management of DM based on a >10% yield and low false-negative rate. Our data demonstrate patients with DM do not recur in an in-transit fashion, which along with the survival outcomes suggest the behavior of DM is consistent with primary cutaneous melanoma of similar thickness rather than an isolated in-transit or distant dermal metastasis from a regressed cutaneous primary.

Education in Cosmetic Procedural Dermatology: Resident Experiences and Perceptions.

Background: Currently, dermatology residency training requires minimal experience in cosmetic procedures which can be achieved through observation. Objective: To assess education in and expectations for cosmetic procedures during dermatology residency. Materials and Methods: A 20-question survey was electronically distributed to 138 Accreditation Council for Graduate Medical Education-accredited dermatology residency training programs. Results: One hundred fifty surveys were returned. While 74 percent of the responding residents reported plans to integrate cosmetic procedures into their future practice, only 36 percent felt adequately trained. Forty-eight percent of residents received one or less didactic lectures annually. Over 95 percent of residents felt that a more formal curriculum in cosmetic procedures would benefit residency education. Conclusion: There appears to be insufficient didactic and clinical training in cosmetic procedures during dermatology residency to meet resident expectations and future practice habits.