Topical methotrexate in dermatology: a review of the literature.

BACKGROUND: Systemic methotrexate (MTX) is a useful treatment for many dermatologic conditions, however, the risk of adverse events prevents its use in patients with minimal or localized disease. Topical application of MTX may be an option to avoid the systemic adverse effects of oral MTX. OBJECTIVE: To assess what is known about the efficacy and safety of topical methotrexate. METHODS: A search on Pubmed was conducted. There were no limits on publication date. RESULTS: A total of 963 articles were discovered. Using our exclusion criteria, 916 articles were excluded; 47 articles were used for full text assessment. Topical MTX has been used primarily in psoriasis but also in mycosis fungoides, lymphomatoid papulosis, and oral precancerous lesions. Optimal delivery system and formulation for adequate penetration is still under investigation. CONCLUSION: The quality of evidence for the utility of topical methotrexate in psoriasis is good, however, for other dermatologic diseases, the quality is poor. Topical MTX with improved delivery methods may be a viable tool against certain localized dermatologic conditions for patients who do not tolerate oral MTX. Further double-blinded randomized controled studies are needed to substantiate the utility of topical methotrexate.

Successful treatment of hidradenitis suppurativa in the setting of Crohn disease with combination adalimumab and ustekinumab.

Herein we report the combination of adalimumab and ustekinumab to successfully treat a 39-year-old woman who presented for evaluation of hidradenitis suppurativa in the setting of Crohn disease of both the small and large intestine. The patient reported previous control of her hidradenitis when she was using adalimumab for her Crohn disease. She had recently been started on ustekinumab for Crohn disease and had flaring of her hidradenitis. The patient re-started on adalimumab weekly and ustekinumab every 8 weeks. After one month, the patient reported clear improvement in her hidradenitis and Crohn disease with the combined therapy.

Validation of a Hidradenitis Suppurativa Self-Assessment Tool.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating dermatologic condition presenting with recurrent abscesses. While there are multiple scales to determine HS severity, none are designed for self-administration. A validated severity self-assessment tool may facilitate survey research and improve communication by allowing patients to objectively report their HS severity between clinic visits. OBJECTIVES: The purpose of this study was to assess a self-administered HS measure. METHODS: An HS self-assessment tool (HSSA) with 10 photographs of different Hurley stages was developed. The tool was administered to patients diagnosed with HS who visited the Wake Forest Baptist Health dermatology clinic over a span of 2 months. Physician-administered Hurley stage was recorded to determine criterion validity. To assess test-retest reliability of the measure, patients completed the HSSA again at least 30 minutes after the first completion. RESULTS: Twenty-four patients completed the measure, and 20 of these patients completed it twice. Agreement between physician-determined Hurley stage and self-determined Hurley stage was 66.7% with a weighted kappa of 0.57 (95% confidence interval [CI]: 0.30-0.84). The weighted kappa for agreement between patients' initial and second completion of the HSSA was 0.81 (95% CI: 0.64-0.99). CONCLUSIONS: The self-administered measure provides moderate agreement with physician-determined Hurley stage and good test-retest reliability.

Female Genital Itch.

Vulvar pruritus is a common complaint among young girls and women presenting to primary care physicians, gynecologists, and dermatologists. Female genital itch is especially disruptive because of its interference with sexual function and intimacy. Causes of vulvar itch are vast and may be inflammatory, environmental, neoplastic, or infectious, often with several causes coexisting simultaneously. Diagnosis may be difficult because of the unique anatomy and inherent properties of genital and perianal skin. Treatment is aimed at eliminating outside irritants, restoring epidermal barrier function, and suppressing inflammation.

Sistema de actividades metodológicas con enfoque de competencia didáctica para profesores de Farmacología I, de la carrera de Medicina: Matanzas / System of methodological activities with an approach of didactical competence for professors of Pharmacology I in the career of Medicine: in Matanzas

Se asumió como enfoque el de las competencias docentes del profesor universitario en el contexto de la universalización. Se utilizaron métodos teóricos, que posibilitaron el estudio en relación con la concepción de la competencia didáctica que se considera básica en los profesores, para sustentar la propuesta diseñada; los métodos empíricos, permitieron recoger información para fundamentar los resultados finales de la investigación. Como procedimientos estadísticos se tuvo en cuenta la estadística descriptiva con frecuencias y porcentajes. El resultado principal de la investigación fue el diseño de un sistema de actividades metodológicas con enfoque de competencia didáctica. Se consideró factible y pertinente la propuesta diseñada, como una de las vías para el desarrollo de competencia didáctica que redunde en el perfeccionamiento del desempeño docente de los profesores universitarios

We assumed as our approach the teaching competences of the university professor in the context of the universalization. We used theoretic methods, allowing the study in relation with the conception of the didactic competence, considered basic in professors, to support de designed proposition. The empirical methods allowed gathering information to sustain the final results of the investigation. As statistical procedure we took into account the descriptive statistics with frequencies and percentages. The main result of the investigation was the design of a system of methodological activities with a didactic competence approach. The designed proposal was considered feasible and pertinent, as a way to develop the didactical competence leading to the improvement of the teaching performance of the university professors

Bullous mastocytosis: report of a patient and a brief review of the literature.

We report a 6-month-old male infant who presented to the pediatric dermatology clinic at Wake Forest University Baptist Medical Center with a generalized bullous eruption since 3 months of age. A sepsis work up was performed at an outside hospital before presentation and did not reveal any evidence of systemic infection. Clinical presentation revealed a well-nourished, appropriate-for-age, 6-month-old boy with multiple tense bullae, some in a "string of pearls" arrangement, on the bilateral upper extremities and trunk. Multiple erosions were also noted. Laboratory evaluation revealed a normal complete blood count. Polymerase chain reaction was negative for herpes simplex virus types I and II. Histologic sections demonstrated a large space of separation between the epidermis and dermis which was filled by a monomorphous infiltrate composed of round to oval cells with centrally placed nuclei, consistent with mast cells. Leder and C-Kit stains were strongly positive, confirming the diagnosis of bullous mastocytosis. Treatment included fluocinonide 0.05% cream and tacrolimus 0.1% ointment to active lesions and silver sulfadiazine 1% cream to erosions. Improvement was noted during follow-up examination.

Intraoperative evaluation of sentinel lymph nodes for metastatic melanoma by imprint cytology.

BACKGROUND: Sentinel lymph node biopsy (SLN) has revolutionized nodal staging. Accurate intraoperative evaluation of SLN permits a single procedure, with lymphadenectomy being performed during the initial operative procedure when the SLN is positive. There is a paucity of literature on intraoperative imprint cytology (IIC) evaluation of the SLN in melanoma. The purpose of this article is to present an update to our experience with IIC for SLN in melanoma. METHODS: Melanoma patients had SLNs examined by IIC. SLNs were bisected, and imprints were made from each half. Imprints were stained with hematoxylin and eosin and with Diff-Quik. Paraffin-embedded sections were examined with multiple hematoxylin and eosin-stained sections from the SLNs in conjunction with immunohistochemical staining for S-100, Melan-A, and HMB-45 proteins. RESULTS: Metastases were identified in 40 (17%) of 229 patients. Of these, 13 patients were detected by IIC (sensitivity, 33%). The negative predictive value was 88%. No false-positive results were identified (specificity, 100%). The positive predictive value was 100%. The accuracy of IIC was 78%. The sensitivity for detecting macrometastases (>2 mm) was better than that for detecting micrometastases (< or =2 mm): 62% vs. 16% (P < .01). Patients with positive SLNs by IIC had lymphadenectomy under the same anesthetic. A total of 533 nonsentinel lymph nodes were identified in 42 patients. Only two patients (8%) had positive nonsentinel lymph nodes after a negative IIC. CONCLUSIONS: IIC is a viable alternative to frozen sectioning when intraoperative evaluation is desired. IIC is significantly more sensitive for macrometastases. IIC evaluation of SLNs in melanoma makes a single operative procedure possible for a significant proportion of patients with regional nodal metastases.

Schwannoma with neuroblastoma-like rosettes: an unusual morphologic variant.

In the past ten years, seven cases of schwannomas with giant fibrillar rosettes or perivascular rosettes have been reported. As these unusual variants of schwannomas had areas with hyperchromatic, small round cells recapitulating the appearance of a neuroblastoma, they received the descriptive name of neuroblastoma-like schwannomas. We herein report two additional cases of this unique variant of schwannoma and provide differential diagnostic considerations.

Microtubule-associated protein 2, a marker of neuronal differentiation, induces mitotic defects, inhibits growth of melanoma cells, and predicts metastatic potential of cutaneous melanoma.

Dynamic instability of microtubules is critical for mitotic spindle assembly and disassembly during cell division, especially in rapidly dividing tumor cells. Microtubule-associated proteins (MAPs) are a family of proteins that influence this property. We showed previously that MAP2, a neuron-specific protein that stabilizes microtubules in the dendrites of postmitotic neurons, is induced in primary cutaneous melanoma but is absent in metastatic melanomas. We proposed that induction of a microtubule-stabilizing protein in primary melanoma could disrupt the dynamic instability of microtubules, inhibit cell division and prevent or delay tumor progression. Here we show, by Kaplan-Meier survival and multivariate Cox regression analysis, that patients diagnosed with MAP2+ primary melanomas have significantly better metastatic disease-free survival than those with MAP2- disease. Investigation of the mechanisms that underlie the effect of MAP2 on melanoma progression showed that MAP2 expression in metastatic melanoma cell lines leads to microtubule stabilization, cell cycle arrest in G2-M phase and growth inhibition. Disruption of microtubule dynamics by MAP2 resulted in multipolar mitotic spindles, defects in cytokinesis and accumulation of cells with large nuclei, similar to those seen in vivo in MAP2+ primary melanomas cells. These data suggest that ectopic activation of a neuronal differentiation gene in melanoma during early tumor progression inhibits cell division and correlates with inhibition or delay of metastasis.

Cutaneous leiomyoma with cytologic atypia, akin to uterine symplastic leiomyoma.

BACKGROUND: Smooth muscle tumors of the skin with cytologic pleomorphism and mitotic activity have traditionally been characterized as leiomyosarcomas, despite having a benign clinical course. In the uterus, there is a smooth muscle tumor known as symplastic leiomyoma, which typically has cytologic pleomorphism without significant mitotic activity. OBJECTIVE: The objective was to illustrate by case report the unusual histologic variant of the cutaneous pilar leiomyoma analogous to the symplastic leiomyoma of the uterus. METHODS: A 54-year-old woman presented with a clinical picture of cutaneous leiomyoma but had histologic features of nuclear hyperchromasia and pleomorphism, but rare mitoses. RESULTS: Management of this patient included excision of the involved area. CONCLUSION: Symplastic leiomyoma is an atypical uterine leiomyoma with cytologic atypia. We present the case of a patient with cutaneous leiomyomas that histologically demonstrated similar features to a uterine symplastic leiomyoma. We believe that this represents a distinct histologic variant of the cutaneous pilar leiomyoma analogous to the symplastic leiomyoma of the uterus.