Angiosarcoma: hiding in plain sight.

Angiosarcoma is a rare, aggressive soft-tissue sarcoma of endothelial origin that necessitates early recognition, diagnosis, and treatment. The most commonly reported presentation consists of violaceous patches and plaques on the head and neck of elderly white men, with fewer reports affecting patients with Skin of Color. Most cases of angiosarcoma are idiopathic and tend to recur locally with early metastasis, conferring a poor prognosis. We report a case of an 83-year-old Fitzpatrick skin type IV man who presented with a large violaceous-to-black mamillated plaque on the frontotemporal scalp that was clinically highly suggestive of cutaneous angiosarcoma. However, unrevealing histopathology complicated our diagnostic process and delayed management. Immunohistochemistry was invaluable in determining the diagnosis of angiosarcoma. Our case highlights the aggressive nature of cutaneous angiosarcoma, necessitating close clinicopathologic correlation to confirm the diagnosis and initiate treatment.

Fractional Ablative Laser Therapy is an Effective Treatment for Hypertrophic Burn Scars: A Prospective Study of Objective and Subjective Outcomes.

OBJECTIVE: The aim of this study is to determine objective and subjective changes in mature hypertrophic burn scars treated with a fractional ablative carbon dioxide (CO2) laser. BACKGROUND: Fractional CO2 laser treatment has been reported to improve burn scars, with increasing clinical use despite a paucity of controlled, prospective clinical studies using objective measures of improvement. METHODS: A multicenter, site-controlled, prospective open-label study was conducted from 2013 to 2016. Objective and patient-reported outcome measures were documented at baseline, at each monthly laser treatment, and 6 months after treatment. Objective measurements employed were: mechanical skin torque to measure viscoelastic properties; ultrasonic imaging to measure scar thickness; and reflectometry to measure erythema and pigmentation. Subjective measures included health-related quality of life, patient and investigator scar assessment scales, and blinded scoring of before and after photographs. Subjects aged 11 years or older with hypertrophic burn scars were recruited. Each subject received 3 monthly treatment sessions with an ablative fractionated CO2 laser. RESULTS: Twenty-nine subjects were enrolled, of whom 26 received at least 1 fractional CO2 laser treatment and 22 received 3 treatments. Mean age of those completing all 3 treatments was 28 years. Statistically significant objective improvements in elastic stretch (P < 0.01), elastic recovery (P < 0.01), extensibility (P < 0.01), and thickness (P < 0.01) were noted. Patient- and physician-reported scar appearance and pain/pruritus were significantly improved (P < 0.01). There was no regression of improvement for at least 6 months after treatment. CONCLUSIONS: Fractional ablative laser treatment provides significant, sustained improvement of elasticity, thickness, appearance, and symptoms of mature hypertrophic burn scars.

Allergic contact dermatitis to 2-octyl cyanoacrylate.

Cyanoacrylates are widely used as topical skin adhesives in emergency departments, clinics, and operating rooms. We report 4 patients who developed allergic contact dermatitis (ACD) following postsurgical closure with 2-octyl cyanoacrylate. These patients were challenged with a novel method of use testing to confirm sensitivity to 2-octyl cyanoacrylate. The popularity of skin adhesives makes this emerging allergen worthy of examination. It is possible that cyanoacrylate allergy currently is underrecognized.

Scalp metastasis of paraspinal alveolar rhabdomyosarcoma.

We describe a 10-year-old girl with paraspinal alveolar rhabdomyosarcoma (RMS) who presented with an asymptomatic soft tissue mass on the left aspect of the parietal scalp of 2 weeks' duration. Biopsy demonstrated metastasis of her RMS. A full-body positron emission tomography (PET) scan revealed multiple areas of increased uptake consistent with extensive metastases. We also discuss the literature on RMS classification and metastasis to the skin.

Iatrogenic autoimmune progesterone dermatitis caused by 17alpha-hydroxyprogesterone caproate for preterm labor prevention.

Preterm birth is the leading cause of perinatal morbidity and mortality in otherwise healthy infants, and the rate of pregnancies complicated by a premature delivery continues to rise. Subsequently, attempts have been made to reduce this rate by using progesterone supplementation during pregnancy. 17alpha-Hydroxyprogesterone caproate (17P), a metabolite of progesterone, also has been used as supplementation during pregnancy to prevent preterm births. We report a case of iatrogenic autoimmune progesterone dermatitis (APD) in a pregnant woman who received 17P therapy. Due to the increased use of 17P, our case could represent an increasingly prevalent entity that dermatologists and obstetricians should recognize. In this article, we discuss our findings and provide a basic review of APD.

Isotretinoin use in a case of chronic granulomatous disease.

Chronic granulomatous disease (CGD) is a rare, inherited disorder, in which phagocytic cells, through an enzyme defect, are unable to produce microbicidal oxidants; affected individuals are thereby unduly susceptible to certain life-threatening bacterial and fungal infections and require lifelong antibiotic and antifungal prophylaxis. We present the case of an adolescent CGD patient whose recalcitrant acne vulgaris and subsequent recurrent facial abscesses were successfully treated with isotretinoin; swift resolution of this and similar patients' acne lesions is paramount, as these lesions may serve as a portal of entry for systemic infections and may pose a significant risk for scarring. Isotretinoin is associated with an increased rate of cutaneous Staphylococcus aureus carriage as well as exuberant granulation responses, both of theoretical concern in CGD patients. The therapeutic outcome of isotretinoin in treatment-resistant cases of acne in CGD patients has not been reported in the literature; we present this case to advocate an underreported use of isotretinoin in the prevention of acne, its subsequent cyst formation, and scarring patients with CGD.

Terbinafine-induced subacute cutaneous lupus erythematosus.

Terbinafine is a synthetic oral allylamine that is used for systemic treatment of microscopy- or culture-proven dermatophyte infections of skin and nails. It is normally well-tolerated and side effects include transient gastrointestinal symptoms and skin reactions that can occur in up to 2.3% of treated patients. Subacute cutaneous lupus erythematosus (SCLE) is a skin reaction that has been reported secondary to use of a variety of drugs. The number of reports of SCLE with terbinafine is limited. We demonstrate 2 patients in one dermatology clinic who presented with a predisposing autoimmune diathesis within 3 months of each other.

Acne arising in an epidermal nevus.

Epidermal nevi are benign congenital lesions that follow Blaschko lines. Epidermal nevi can demonstrate a variety of histologic patterns and contain hamartomatous hyperplasia of any epidermal or adnexal structure. We present the first reported instance of acne arising strictly within a preexisting keratinocytic epidermal nevus during puberty, which is a demonstration of genetic mosaicism in pilosebaceous units.

Interstitial granulomatous lesions as part of the spectrum of presenting cutaneous signs in pediatric sarcoidosis.

Skin findings in childhood sarcoidosis vary greatly, but only a few occurrences have been published in which the histopathology has been characterized well. We describe a child with sarcoidosis in whom the cutaneous findings were atypical, resembling granuloma annulare. Histologic examination of these cutaneous lesions, however, revealed areas of sarcoid-like epithelioid cell granulomas, a palisading granulomatous process with features of granuloma annulare, as well as palisading neutrophilic and granulomatous dermatitis and interstitial granulomatous dermatitis. This underscores the variability of skin findings in childhood sarcoidosis--even within the same patient--and suggests that sarcoidosis should be considered in the differential diagnosis of children initially diagnosed with granulomatous skin lesions, such as granuloma annulare, palisading neutrophilic, and granulomatous dermatitis or interstitial granulomatous dermatitis, who demonstrate associated signs of systemic disease.

Management of trauma and burn scars: the dermatologist's role in expanding patient access to care.

Recent advances in laser surgery and our understanding of wound healing have ushered in a new era of trauma and burn scar management. Traditional therapy has centered around scar excision followed by primary closure or tissue replacement with flaps and grafts. This approach represents a perpetuation of the common fallacy that extensive scar improvement requires extensive surgical intervention. Laser surgery in conjunction with pharmacotherapy and minor tissue-conserving surgery produces well-healed and remodeled existing tissue that provides the most natural appearance and function of the skin. Now, patients' hypertrophic, contracted, and disfiguring scars represent their most valuable reconstructive anatomy. With this paradigm shift, dermatologists are uniquely positioned to provide transformative and cost-effective scar therapy due to their proficiency in the necessary treatment modalities and expertise in the utilization of local anesthesia. We hope to further expand military and civilian patient access to such care in their local community through peer education and advocacy. We present a brief overview and outline of scar treatment practices that can be performed by dermatologists in office using devices and techniques they often already possess.

Diffuse Urticarial Reaction Associated with Titanium Dioxide Following Laser Tattoo Removal Treatments.

IMPORTANCE: Local and generalized allergic reactions following laser tattoo removal have been documented, but are rare. To our knowledge, this is the fourth documented case of widespread urticarial eruptions following laser tattoo removal treatment. Unlike previously documented cases, this patient's reaction was found to be associated with titanium dioxide within the tattoo and her symptoms were recalcitrant to medical therapy. OBSERVATIONS: A 46-year-old female experienced diffuse urticarial plaques, erythema, and pruritis following multiple laser tattoo removal treatments with an Nd:YAG laser. The systemic allergic reaction was recalcitrant to increasing doses of antihistamines and corticosteroids. The tattoo was finally surgically excised. The excised tissue was analyzed by scanning electron microscopy and energy-dispersive X-ray analysis and contained high levels of titanium dioxide. Two weeks following the excision, and without the use of medical therapy, the patient had complete resolution of her generalized urticaria. CONCLUSIONS: Ours is the first documented case of a diffuse urticarial reaction following laser tattoo removal treatments that shows a strong association to titanium dioxide within the tattoo pigment. Herein, we describe a novel surgical approach to treat recalcitrant generalized allergic reaction to tattoo pigment.

A case of genital porokeratosis and review of literature.

We present a case of a 64-year-old uncircumcised male who initially presented to the provider with a 1 year history of a solitary lesion on the glans penis that was clinically diagnosed as porokeratosis of Mabelli. A biopsy on a follow-up visit confirmed provider's clinical suspicion. This article highlights the progression and treatment options for porokeratosis on the male genitalia.

Bilateral lower extremity inflammatory lymphedema in Air Force basic trainees: clinical and epidemiologic study of a new disease entity.

IMPORTANCE: This observational study characterizes a new clinical condition identified in 55 military trainees. OBJECTIVE: To determine the incidence and underlying cause of bilateral lower extremity inflammatory lymphedema in Air Force basic trainees. DESIGN, SETTING, AND PARTICIPANTS: An observational study was conducted at Lackland Air Force Base in San Antonio, Texas. Participants included 14 243 Air Force basic trainees who entered training between September 2011 and January 2012 and the 55 trainees (0.4%) who developed bilateral lower extremity inflammatory lymphedema that occurred during the 8½-week basic training course. Two modifiable risk factors were evaluated: vaccine reaction and newly issued military footwear (combat boots and boot socks). INTERVENTIONS: During November 2011, all new trainees wore only white socks and running shoes rather than the issued military footwear. During December 2011 and January 2012, the scheduled administration of tetanus/diphtheria/acellular pertussis and meningococcal vaccines, respectively, was delayed by 1 week for all new trainees. A full medical record review was conducted for every confirmed case of bilateral lower extremity inflammatory lymphedema. MAIN OUTCOMES AND MEASURES: Identification of incident cases, symptom onset, antimicrobial treatment, immunization reaction, laboratory studies, specialty referral, and biopsy. RESULTS: Fifty-four of the 55 incident cases (98%) of bilateral lower extremity inflammatory lymphedema occurred during the first 120 hours of training. Alterations in the timing of the military footwear used and selected vaccine administration had no effect on the incidence of new cases. Two participants (4%) experienced symptom onset before receipt of the vaccines. Oral antimicrobial medications were not found to speed symptom resolution compared with conservative treatment measures (P = .34). One incident case was diagnosed as leukocytoclastic vasculitis by tissue examination. CONCLUSIONS AND RELEVANCE: Multiple training-related risk factors were ruled out as sources of bilateral lower extremity inflammatory lymphedema. Cases are likely secondary to prolonged standing with resultant gravity-dependent venous congestion and inflammatory vasculitis. The potential roles of undiagnosed venous reflux disease and the military physical training environment in these cases remain to be elucidated.

The management of pemphigus vulgaris in a burn intensive care unit: a case report and treatment review.

Pemphigus vulgaris is a rare, potentially fatal, autoimmune blistering disease of the skin and mucous membranes. Treatment of this disease is problematic because of a lack of high-grade, evidence-based recommendations, the side-effect profiles of the therapies available, and the extensive supportive care that afflicted patients require. The authors present the unfortunate course of a patient with severe pemphigus vulgaris who was admitted to the U.S. Army Institute of Surgical Research Burn Center, to demonstrate the potential complications of therapy. Given the patient's complex course, the authors reviewed the literature and share in this article the most up-to-date treatment recommendations for patients with pemphigus vulgaris. The authors' review of the literature supports using conventional therapy consisting of high-dose corticosteroids and an adjuvant immunosuppressant for mild to moderate cases of pemphigus vulgaris. The immunosuppresants recommended are mycophenolate mofetil, azathioprine, and cyclophosphamide, in order of preference, based on their side-effect profiles and steroid-sparing effects. For severe or recalcitrant cases of pemphigus vulgaris, the authors recommend adding rituximab as early as possible. If increased risk of infection is of particular concern, the use of intravenous immunoglobulin in place of rituximab is advised.