Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma using Mel-5 immunostaining: an update from the University of Minnesota.

BACKGROUND: Mohs micrographic surgery (MMS) is gaining acceptance as a treatment for lentigo maligna (LM) and lentigo maligna melanoma (LMM), especially with the use of melanocyte-staining immunohistochemical (IHC) stains. In 2006, we reported our 4-year experience with Mel-5 immunostaining, with only one recurrence noted in 200 patients after a mean follow-up of 38.4 months.(1) OBJECTIVES: We present an update regarding our 13-year experience with the use of Mel-5. METHODS AND MATERIALS: Patients with primary or recurrent LM or LMM (n = 260) underwent MMS with Mel-5; 174 were followed up to evaluate for recurrence, with a mean follow-up of 34 months. The 200 patients described in the initial case series from 1999 to 2003 were also followed. RESULTS: Of the 460 patients treated from January 1999 to December 2011, five recurrences were noted in four patients; one in the initial case series and four in this new, updated series, including one re-recurrence from the initial series. One melanoma-related death occurred in a patient intermittently lost to follow-up. CONCLUSION: MMS with Mel-5 immunostaining continues to yield excellent results in the treatment of LM and LMM.

Type I allergy to insulin: case report and review of localized and systemic reactions to insulin.

Allergic reactions to insulin preparations are not uncommon. Although patients often present with skin symptoms, most articles on insulin allergy are published in endocrinology and allergy journals. The purpose of this report is to describe a case of localized type I allergy to insulin as well as provide a review of the classification of insulin allergy, methods of evaluation, and management options.

Black-spot poison ivy.

In black-spot poison ivy dermatitis, a black lacquerlike substance forms on the skin when poison ivy resin is exposed to air. Although the Toxicodendron group of plants is estimated to be the most common cause of allergic contact dermatitis in the United States, black-spot poison ivy dermatitis is relatively rare.

Evaluation of prospectively collected presenting signs/symptoms of biopsy-proven melanoma, basal cell carcinoma, squamous cell carcinoma, and seborrheic keratosis in an elderly male population.

BACKGROUND: Presenting signs/symptoms of skin cancer may aid in earlier detection and diagnosis. OBJECTIVE: We sought to compare prospectively collected, presenting signs/symptoms of malignant melanoma (MM), basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and seborrheic keratosis (SK). METHODS: This analysis was part of a larger study on teledermatology involving 3039 skin neoplasms in 2152 patients at a Department of Veterans Affairs medical center. At presentation, participants were asked about signs/symptoms of specific skin lesions. In all, 912 biopsy-proven MM (39), BCC (411), SCC (238), and SK (224) were included in this analysis. Pearson chi(2) analyses were used to test associations of lesion type and specific signs/symptoms in pairwise comparisons. RESULTS: "No symptoms" was reported more often with MM (82%) as compared with BCC (relative risk [RR] 2.26, confidence interval [CI] 1.86, 2.75), SCC (RR 3.31, CI 2.54, 4.32), or SK (RR 2.0, CI 1.61, 2.48; all P < .0001). Tenderness was more commonly reported with SCC (40%) as compared with MM (RR 15.9, CI 2.28, 110.69), SK (RR 3.0, CI 2.11, 4.39), or BCC (RR 2.6, CI 1.97, 3.38; all P < .0001). Bleeding was more commonly reported with BCC (37%) as compared with SK (RR 2.3, CI 1.67, 3.20), SCC (RR 1.6, CI 1.22, 2.05), or MM (RR 29.8, CI 1.89, 469.65; all P

Genetics of nickel allergic contact dermatitis.

Nickel sulfate is the most frequently detected cause of allergic contact dermatitis in the world; the prevalence of nickel allergic contact dermatitis is between 8 and 11% in the general female population. Although it is well recognized that environmental factors are important in the pathogenesis of this dermatitis, some investigators have hypothesized that genetic factors are important as well. This review summarizes animal and human studies evaluating genetic factors in the development of allergic contact dermatitis from nickel.

Allergic contact cheilitis from benzophenone-3 in lip balm and fragrance/flavorings.

Benzophenones are the most frequent cause of sunscreen allergy. Photoallergic and nonphotoallergic reactions may occur. We present a patient with allergic contact dermatitis of the lips from benzophenone-3 in a lip balm and fragrance/flavorings.

Shoe allergens: retrospective analysis of cross-sectional data from the north american contact dermatitis group, 2001-2004.

BACKGROUND: Chemicals used in leather tanning, rubber processing, and/or adhesives are the most often-cited culprits in footwear dermatitis. Patch testing patients with suspected shoe dermatitis is essential for diagnosis and management. OBJECTIVES: The four goals for this study were to (1) determine the frequency of allergens associated with a shoe source in North American Contact Dermatitis Group (NACDG) patients with footwear allergic contact dermatitis; (2) compare these results to allergen frequencies from other published studies; (3) quantify the number of shoe-related reactions that were not identified with the NACDG standard series; and (4) identify relevant allergens not included on the NACDG standard series, based on data from other published studies. METHODS: The NACDG patch-tested 10,061 patients between 2001 and 2004. Data were retrospectively analyzed by (1) allergen source coded as "shoe," (2) site of dermatitis as "feet," and (3) diagnosis of "allergic contact dermatitis." RESULTS: Among the 109 NACDG patients with allergic contact dermatitis (ACD) of the foot and a shoe source of allergens, p-tertiary butylphenol formaldehyde resin, an adhesive, was the most common allergen, accounting for 24.7% of positive patch-test results, followed by potassium dichromate (17.5%) and carba mix (11.7%). When the data were examined according to groups of allergens, rubber chemicals (40.4%) were the most frequent allergens, followed by adhesives (32.5%), and leather components (20.1%). When data from published studies were pooled, potassium dichromate (31.5%) was the most frequent allergen, followed by p-tertiary butylphenol formaldehyde resin (17.1%) and cobalt chloride (12.9%). NACDG patients were statistically more likely to have positive patch-test reactions to p-tertiary butylphenol formaldehyde resin and statistically less likely to have a positive patch-test reaction to potassium dichromate than patients represented in pooled data from past studies. Nineteen (17.4%) of the 109 NACDG patients with ACD of the foot and a shoe source of allergens were identified as having a shoe source of a relevant allergen not included in the NACDG standard series. CONCLUSIONS: In NACDG patients, the most common individual shoe allergen was p-tertiary butylphenol formaldehyde resin. As a group, rubber chemicals were most common, a finding consistent with those of other studies.

Physician skin examinations for melanoma screening.

A variety of estimates of the value and impact of physician skin examinations (PSEs) in screening for melanoma have been published. Although current melanoma screening guidelines vary, new evidence supports improved melanoma outcomes associated with PSEs. In this systematic review, we evaluated 5 observational studies of the impact of PSEs on melanoma thickness at diagnosis and melanoma mortality rates. Although definitive evidence from randomized controlled trials supporting improved health outcomes associated with PSEs is lacking, these well-designed observational studies have found PSEs to be correlated with thinner melanomas at diagnosis and reduced melanoma mortality rates.

Nickel hypersensitivity: a clinical review and call to action.

Nickel sensitivity is common and increasing in prevalence. This review discusses nickel sensitivity and its association with body piercing and other environmental factors, occupational relevance, and potential implications for implantable metal medical devices. In addition, current European legislation that limits the release of nickel from jewelry is highlighted and an argument for similar legislation elsewhere is presented.

Occupation-related contact dermatitis in North American health care workers referred for patch testing: cross-sectional data, 1998 to 2004.

BACKGROUND: Contact dermatoses are common in health care workers (HCWs). OBJECTIVES: To (1) estimate the prevalence of occupation-relevant allergic contact dermatitis (ACD) among health care workers patch-tested from 1998 to 2004 by the North American Contact Dermatitis Group (NACDG), (2) characterize responsible allergens among health care workers overall as well as in specific health care occupational subgroups, and (3) compare these results to those of nonhealth care workers. METHODS: Between 1998 and 2004, 15,896 patients were patch-tested by the NACDG. Occupation-related allergic patch-test results were analyzed among HCWs, subgroups of HCWs, and non-HCWs. RESULTS: 1,255 patients (7.9%) were HCWs. Female gender (HCWs, 86.2%; non-HCWs, 63.6%) and hand involvement (HCWs, 54.7%; non-HCWs, 27.8%) were more common in HCWs (p < .05); 18.2% of HCWs and 6.6% of non-HCWs had occupation-related allergens of current clinical relevance. Thiuram mix (HCWs, 8.87% non-HCWs, 0.90%) and carba mix (HCWs, 5.43%; non-HCWs, 0.87%) were the most common occupation-related currently relevant antigens in HCWs and were more common in HCWs than in non-HCWs (p < .05). CONCLUSIONS: Among HCWs patch-tested by the NACDG between 1998 and 2004, the most common allergens were thiuram mix and carba mix, followed by glutaraldehyde, cocamide diethanolamine, and chloroxylenol. Gloves, sterilizing solutions, and soaps were common sources of responsible allergens.

Patch-test reactions to topical anesthetics: retrospective analysis of cross-sectional data, 2001 to 2004.

BACKGROUND: Allergy to topical anesthetics is not uncommon. The cross-reactivity among topical anesthetics and the screening value of benzocaine alone are not well understood. OBJECTIVES: The goals for this study were: (1) to evaluate the frequency and pattern of allergic patch-test reactions to topical anesthetics, using North American Contact Dermatitis Group (NACDG) data, and (2) to compare these results to allergen frequencies from other published studies. METHODS: The NACDG patch-tested 10,061 patients between 2001 and 2004. In this analysis patients were included who had positive patch-test reactions to one or more of the following: benzocaine, lidocaine, dibucaine, tetracaine, and prilocaine. RESULTS: Of patch-tested patients, 344 (3.4%) had an allergic reaction to at least one anesthetic. Of those, 320 (93.0%) had an allergic reaction to only one topical anesthetic. Overall, reactions to benzocaine (50.0%, 172 of 344) were most prevalent, followed by reactions to dibucaine (27.9%, 96 of 344); however, reactions to dibucaine were significantly more frequent in Canada than in the United States (relative risk [RR], 2.31; 95% confidence interval [CI], 1.67-3.20; p < .0001). Of patients reacting to more than one anesthetic, most (79%, 19 of 24) reacted to both an amide and an ester. CONCLUSIONS: Of the topical anesthetics tested, benzocaine was the most frequent allergen overall. Over 50% of allergic reactions to topical anesthetics in this study would have been missed had benzocaine been used as a single screening agent. Cross-reactivity patterns were not consistent with structural groups.

Digital polarized light dermoscopy of clinically nonpigmented dermal nevi.

BACKGROUND: Hand-held dermoscopy improves the malignant/benign excision ratio for melanocytic lesions. Much has been described about its use in pigmented lesions; however, the use of dermoscopy in clinically nonpigmented lesions is less well studied. Existing studies have used a combination of traditional immersion dermoscopy and polarized light dermoscopy. This is the first study, to our knowledge, to strictly use digital polarized light dermoscopy for the evaluation of clinically nonpigmented, biopsy-proven dermal nevi. OBJECTIVE: The goal of this study was to describe the dermoscopic features of clinically nonpigmented, biopsy-proven dermal nevi using digital polarized light images. METHODS AND MATERIALS: The dermoscopic features of 32 histopathologically confirmed, clinically nonpigmented, dermal nevi were evaluated. Images were obtained with a digital camera equipped with an epiluminescence microscopy attachment (polarized light); no liquid interface was used. RESULTS The most frequent dermoscopic feature of 32 clinically nonpigmented, biopsy-proven dermal nevi was brown pigment (78%) followed by white areas (53%), comma-shaped vessels (50%), hair (47%), hairpin vessels (22%), comedolike openings (22%), and dotted vessels, respectively (19%). CONCLUSIONS: The most common dermoscopic features (using polarized light) of clinically nonpigmented, biopsy-proven dermal nevi are brown pigment, white areas, comma-shaped vessels, and hair.