The skin and hypercoagulable states.

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.

Scalp dysesthesia related to cervical spine disease.

BACKGROUND: Scalp dysesthesia is characterized by abnormal sensations of the scalp in the absence of any other unusual physical examination findings. The pathogenesis of this condition is unknown but has been reported in the setting of underlying psychiatric disorders. Other localized pruritic syndromes, including brachioradial pruritus and notalgia paresthetica, have been associated with pathologic conditions of the spine and have been successfully treated with gabapentin. OBSERVATIONS: Among 15 women identified in a retrospective review of medical records as having been seen with scalp dysesthesia, 14 patients had cervical spine disease confirmed by imaging. The most common finding on imaging was degenerative disk disease, with 10 of 14 patients having these changes at C5-C6. Other abnormal imaging findings included anterolisthesis, osteophytic spurring, lordosis, kyphosis, and nerve root impingement. A gabapentin regimen (topical or oral) had been recommended to 14 patients; of 7 patients who were followed up, 4 patients noted improvement in symptoms when taking gabapentin. CONCLUSIONS: Patients with scalp dysesthesia also had abnormal cervical spine images. Chronic muscle tension placed on the pericranial muscles and scalp aponeurosis secondary to the underlying cervical spine disease may lead to the symptoms of scalp dysesthesia.

Etiology, diagnosis, and therapeutic management of granuloma annulare: an update.

Granuloma annulare (GA) is a common cutaneous disorder classically presenting as annular groups of skin-colored to erythematous papules without epidermal change localized to the dorsal hands and/or feet. In addition to the localized form, there are variants including generalized (including generalized annular GA, disseminated papular GA, and atypical generalized GA), subcutaneous, and perforating GA, providing for a wide spectrum of clinical lesions. The etiology of GA remains unknown and several systemic associations have been proposed but not proven, including diabetes mellitus, malignancy, thyroid disease, and dyslipidemia. The diagnosis of GA relies on clinicopathological correlation, with a skin biopsy confirming the histological features of the disease, including palisading granulomas, collagen degeneration, mucin, and a lymphohistiocytic infiltrate. Localized GA is often asymptomatic and self-limited within 2 years; however, the patient may desire treatment for cosmetic reasons, with topical and intralesional corticosteroids as the mainstays of therapy. When GA is generalized, disseminated, or atypical, a more thorough medical workup for underlying diseases may be considered depending on the physical examination, a thorough review of systems, comorbidities, and clinical suspicion. Treatment is often challenging for generalized GA, especially because of its recalcitrant nature and a lack of evidence-based therapy. Over 30 different treatments have been described for GA with variable results; however, the majority of these have been single case reports, small case series, or retrospective studies. Reported treatments for GA include topical, intralesional, intramuscular, and oral medications (steroidal vs. non-steroidal); biologic agents; surgical interventions; phototherapy; and laser treatments. When selecting a systemic therapy for a patient with GA, multiple variables must be considered, such as baseline blood evaluations, comorbidities, drug interactions, compliance, adverse effect profiles, prior treatments, and reproductive status. This evidence-based review will focus on the advances made in the twenty-first century regarding the etiology, diagnosis, and therapeutic management of GA.