Segmental cutaneous piloleiomyomata.

A 60-year-old white man seen in consultation for "chronic zoster" presented with a 30-year history of persistent, painful cutaneous lesions on his right flank. His pain was episodic and exacerbated by physical touch and emotional stress. He denied lesion sensitivity to cold or heat. Application ofcapsaicin cream had been without benefit. There was no family history of similar lesions. Physical examination revealed multiple, pink to violaceous, firm, tender nodules (3-7 mm) arising on the right flank in a segmental distribution (Figure 1). No other lesions were noted. A biopsy specimen showed findings of dermal proliferation of spindle-shaped cells with eosinophilic cytoplasm and blunt-ended nuclei without cytologic atypia (Figure 2A and Figure 2B). All of these findings were compatible with a diagnosis of segmental cutaneous piloleiomyomata. He declined surgical or medical intervention.

Unilateral facial angiofibromas without other evidence of tuberous sclerosis: case report and review of the literature.

Bilateral facial angiofibromas are common cutaneous manifestations of tuberous sclerosis, an autosomal-dominant disease characterized by hamartomas of multiple organs. Papules in patients with tuberous sclerosis typically appear between 4 and 10 years of age, becoming more extensive during puberty before stabilizing. We present a 28-year-old man with unilateral facial angiofibromas, which may represent a segmental form of tuberous sclerosis.

Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus.

OBJECTIVE: To evaluate and compare the efficacy of the Semont liberatory maneuver on "objective" benign paroxysmal positional vertigo (BPPV) defined as vertigo with geotropic nystagmus in Dix-Hallpike positioning versus "subjective" BPPV defined as vertigo without nystagmus in Dix-Hallpike positioning. STUDY DESIGN: Retrospective chart review. METHODS: One hundred sixty-two patients with positional vertigo during Dix- Hallpike positioning were identified. Patients were evaluated for the presence or absence of nystagmus. All patients underwent the Semont liberatory maneuver. The patient's condition at follow-up was documented at 3 weeks as complete, partial, or failure. Repeated procedures were performed if necessary. RESULTS: There were 127 cases of objective BPPV and 35 cases of subjective BPPV. Overall, 90% of all patients tested had significant improvement of their vertigo after 1.49 maneuvers on average. Improvement was seen in 91% of patients with objective BPPV after 1.59 maneuvers on average, compared with 86% in subjective BPPV after 1.13 maneuvers on average (chi2 test, not significant [P = .5]). Patients with a history of traumatic origin or cause had an overall success rate of 81% compared with 92% for nontraumatic causes or origins (chi2 test, not significant [P = .1]). Recurrences were seen in 29% of patients after a successful initial maneuver; however, 96% of these patients responded to further maneuvers. Four patients with persistent symptoms after conservative management underwent posterior semicircular canal occlusion with resolution of symptoms. CONCLUSION: The Semont liberatory maneuver provides relief of vertigo in patients with positional vertigo, even in patients without objective nystagmus.

Skin cancer after transplantation.

Advances in transplantation technique and posttransplantation immunosuppression have resulted in continual improvements in survival and quality of life of transplant recipients. The improved quality of life afforded in the posttransplantation period allows patients to lead more active lifestyles, which often includes increased exposure to solar radiation. This growing population of active, immunosuppressed individuals is at marked risk, up to 65 times that of the general population, for the development of cutaneous neoplasms with associated morbidity and mortality. Prevention, prompt recognition, and effective treatment of skin cancer in this immunosuppressed population are vital.

Melanoma associated with a dermatofibroma.

BACKGROUND: Dermatofibromas are common benign cutaneous fibrohistiocytic neoplasms, whereas melanomas are potentially aggressive malignancies. Differentiating these two entities can occasionally be difficult. METHODS: We report the case of a 56-year-old female presenting with a firm pink papule on the left thigh. RESULTS: Histopathology revealed atypical melanocytes in the epidermis and papillary dermis with numerous mitotic figures and intraepidermal pagetoid spread. Within the dermis was a poorly demarcated collection of epithelioid and spindled cells with intermixed keloidal collagen. The atypical melanocytes stained for MART-1 and S-100, whereas the underlying fibrohistiocytic tumor took up factor XIIIa immunostain, confirming the diagnosis of invasive malignant melanoma occurring in association with a dermatofibroma. CONCLUSIONS: This case emphasizes the role of immunohistochemical stains in correctly diagnosing melanocytic and histiocytic neoplasms.

Use of topical immunomodulators in organ transplant recipients.

Solid organ transplant recipients are a growing population at increased risk for the development of cutaneous premalignant and malignant lesions, resulting in significant morbidity and mortality. Topical immunomodulators, in particular imiquimod, have shown efficacy in the management of multiple malignant, precancerous, and viral conditions. The ability to locally induce an immune response, presumably against tumor and viral antigens, and induce apoptosis makes topical immunomodulators a promising therapeutic option in organ transplant recipients. Although limited, data have begun to accumulate on the use of imiquimod in transplant patients for the management of superficial, nodular, and infiltrative basal cell carcinomas; in situ and invasive squamous cell carcinomas; condyloma acuminata; and common warts. As more experience is gathered, the role of imiquimod and other topical immunomodulators in the care of OTRs will be clarified. The authors reviewed the existing data on the use of topical imiquimod in OTRs with mention of its presumed mechanisms of action and other immunomodulators with potential efficacy against cancerous and precancerous lesions.

Multiple atypical fibroxanthomas in a cardiac transplant recipient.

BACKGROUND: Solid organ transplant recipients have an increased incidence of multiple cutaneous neoplasms. OBJECTIVE: We hope to draw attention to the potential risk for organ transplant recipients to develop atypical fibroxanthomas. METHODS: A review of the patient's medical record was performed and summarized as a case report. RESULTS: We present the case of a cardiac transplant recipient who developed three atypical fibroxanthomas. This is the first reported case of multiple atypical fibroxanthomas in an organ transplant recipient. CONCLUSION: Atypical fibroxanthomas are uncommon cutaneous malignancies for which transplant recipients may be at increased risk.

Systemic strategies for chemoprevention of skin cancers in transplant recipients.

BACKGROUND: Solid organ transplant recipients (OTRs) are a growing population at high risk for cutaneous neoplasms, resulting in significant post-transplant morbidity and mortality. Management of malignant and pre-malignant cutaneous lesions in transplant recipients is challenging, making prevention of such neoplasms paramount. The objectives of the present study are to review and analyze systemic strategies for chemoprevention of malignant and pre-malignant cutaneous neoplasms in OTRs. METHODS: MEDLINE and PubMed searches were performed to identify studies with original data quantifying the effects of systemic agents on the development of malignant cutaneous neoplasms in patients with solid organ transplants. RESULTS: We identified nine studies describing 111 transplant recipients that quantified the effects of oral retinoids on cutaneous neoplasms. A majority of the studies found a decrease in the number of malignant and pre-malignant cutaneous lesions in patients treated with systemic retinoids, with several studies noting increased benefit in those patients with multiple previous skin cancers. Multiple studies described a rebound effect, with increased numbers of neoplasms occurring following discontinuation of retinoids. Side effects often limited dosing, but required discontinuation of retinoids in a minority of patients. No studies were identified that adequately quantified the effects of other systemic agents on skin cancer incidence in this population. CONCLUSIONS: Although systemic retinoids are frequently used for chemoprevention of cutaneous malignancies in OTRs, the data supporting their use are composed largely of small uncontrolled case reports and case series. However, the available data suggest that retinoids have chemopreventative effects in this population. Although optimal dosing and indications for initiation of systemic retinoid therapy are not conclusive from the data, it suggests that retinoids are most effective in patients with multiple previous non-melanoma skin cancers. Side effects and beneficial effects were noted across a wide range of doses, suggesting that retinoids should be initiated at a low dose and increased as tolerated to a minimally effective dose. Further investigation through randomized controlled trials is needed to further clarify the tolerability and efficacy of multiple dosing regimens on the incidence of pre-malignant and malignant lesions in transplant recipients. The therapeutic role of other systemic agents in the transplant population has not been established.