Skin diseases of the breast and nipple: Inflammatory and infectious diseases.

Certain dermatologic conditions are unique to the breast and nipple, whereas others may incidentally involve these structures. All require a nuanced approach to diagnosis and treatment because of the functional, sexual, and aesthetic importance of this area. The lactating patient requires special management because certain treatment options are contraindicated. All dermatologic conditions involving the breast and nipple require careful evaluation because malignancy of the breast can be mistaken for a benign condition or may trigger the development of certain dermatologic conditions. The second article in this continuing medical education series reviews common and uncommon inflammatory and infectious conditions of the breast and nipple and provides insight into both the diagnosis and the treatment of this heterogeneous group of diseases. For the purposes of this article, these conditions are divided into 4 distinct categories: 1) dermatitis; 2) radiation-induced changes; 3) mastitis; and 4) miscellaneous dermatologic conditions of the breast and nipple.

Skin diseases of the breast and nipple: Benign and malignant tumors.

The evaluation and management of dermatologic diseases of the breast and nipple requires an understanding of the unique anatomy of the breast and nipple and an awareness of the significant emotional, cultural, and sexual considerations that may come into play when treating this anatomic area. The first article in this continuing medical education series reviews breast anatomy, congenital breast anomalies, and benign and malignant breast tumors. An emphasis is placed on inflammatory breast cancer and breast cancer with noninflammatory skin involvement and on cutaneous metastases to the breast and from breast cancer. Familiarity of the dermatologist with the cutaneous manifestations of breast cancer will facilitate the diagnosis of breast malignancy and assist with staging, prognostication, and evaluation for recurrence. This article also discusses genodermatoses that predispose to breast pathology and provides imaging recommendations for evaluating a palpable breast mass.

Congenital multiple clustered dermatofibroma in a 12-year-old girl.

Congenital multiple clustered dermatofibroma (MCDF) is a rare, idiopathic, benign tumor presenting at birth as an asymptomatic hyperpigmented patch that is stable until puberty, at which time it enlarges and develops papules. Ultimately, MCDF appears to follow a stable, benign course. We present a case of a 12-year-old girl with congenital MCDF. To our knowledge, this is only the third reported case of congenital presentation of MCDF and the only case featuring atrophoderma-like depression.

Use of Upadacitinib in Refractory Esophageal Lichen Planus: Endoscopic Improvement in "Planus" Sight.

Although rarely reported, esophageal lichen planus is a chronic inflammatory disease that can lead to debilitating symptoms. It is reported to affect adult women in the fourth and fifth decades of life. Treatment ranges from medical therapy to endoscopic dilation. Owing to underdiagnoses and limited data on therapies, little guidance is provided in the literature regarding treatment of refractory cases. We report a case of a 68-year-old woman with esophageal lichen planus who had symptoms and lack of histological improvement despite being on budesonide and mycophenolate. She was then transitioned to upadacitinib 30 mg daily and had significant symptomatic and endoscopic improvement.

Fungal melanonychia.

Fungal melanonychia is a relatively rare nail disorder caused by nail infection that produces brown-to-black pigmentation of the nail unit. The number of organisms implicated as etiologic agents of fungal melanonychia is increasing, and the list currently tops 21 species of dematiaceous fungi and at least 8 species of nondematiaceous fungi. These superficial infections may clinically mimic subungual melanoma and are often not responsive to traditional antifungal therapy. This article reviews the literature on fungal melanonychia and the role of fungal melanin in infection.

Risk factors and prevention strategies for cutaneous squamous cell carcinoma in transplant recipients.

It has been well established that organ transplant recipients (OTRs) are at an increased risk of skin cancer. Studies vary on the exact degree of this risk, but it is likely somewhere between 60 and 100 times more likely that an OTR patient will develop skin cancer. The management of skin cancer burden in OTRs requires a multidisciplinary approach with the transplant team, dermatologists, and oncology. In many major hospital systems, there are dedicated transplant dermatology clinics that allow for specialized and more frequent screenings of this high-risk population. Here we discuss the pathogenesis, presentation, and treatment options used by dermatologists to prevent and treat commonly found skin cancers in this vulnerable population.

Keratinocytic epidermal nevus with ipsilateral breast hypoplasia.

Breast hypoplasia has been reported in some epidermal nevus syndromes, but not with a keratinocytic epidermal nevus. Herein, we describe the first case of breast hypoplasia associated with a keratinocytic epidermal nevus. Keratinocytic epidermal nevi have been shown to be associated with somatic mutations in FGFR3, PIK3CA, and HRAS. We hypothesize that hypoplasia may be due to a local mutation in the FGFR3 gene or increased androgen receptors in affected breast tissue. The patient was treated with CO2 laser with good cosmetic outcome.

Deer ked: a Lyme-carrying ectoparasite on the move.

Lipoptena cervi, known as the deer ked, is an ectoparasite of cervids traditionally found in northern European countries such as Norway, Sweden, and Finland. Although rarely reported in the United States, this vector recently has been shown to carry Borrelia burgdorferi and Anaplasma phagocytophylum from specimens collected domestically. Importantly, it has been suggested that deer keds are one of the many disease-carrying vectors that are now found in more expansive regions of the world due to climate change. We report a rare sighting of L cervi in Connecticut. Additionally, we captured a high-resolution photograph of a deer ked that can be used by dermatologists to help identify this disease-carrying ectoparasite.

Analogs of human genetic skin disease in domesticated animals.

Genetic skin diseases encompass a vast, complex, and ever expanding field. Recognition of the features of these diseases is important to ascertain a correct diagnosis, initiate treatment, consider genetic counseling, and refer patients to specialists when the disease may impact other areas. Because genodermatoses may present with a vast array of features, it can be bewildering to memorize them. This manuscript will explain and depict some genetic skin diseases that occur in both humans and domestic animals and offer a connection and memorization aid for physicians. In addition, we will explore how animal diseases serve as a model to uncover the mechanisms of human disease. The genetic skin diseases we will review are pigmentary mosaicism, piebaldism, albinism, Griscelli syndrome, ectodermal dysplasias, Waardenburg syndrome, and mucinosis in both humans and domesticated animals.

Ecthyma gangrenosum secondary to methicillin-sensitive Staphylococcus aureus.

Ecthyma gangrenosum (EG) is a well-described skin manifestation of Pseudomonas aeruginosa septicemia in immunocompromised patients. However, it can be seen in association with other bacteria, viruses, and fungi. We report a case of a 54-year-old African American female with metastatic gastric adenocarcinoma and recent chemotherapy and neutropenia who developed EG-like lesions due to methicillin-susceptible Staphylococcus aureus. We also review the literature to evaluate all reported cases of S aureus-associated EG and their clinical presentation, diagnosis, and treatment.

Spotlight on tavaborole for the treatment of onychomycosis.

Onychomycosis is a fungal nail plate infection that has been increasing in prevalence. A variety of oral and topical anti-fungal agents are currently available but their use is limited by their adverse effect profile, drug-drug interactions, and limited efficacy. Therefore, there is a great need for newer anti-fungal agents. Tavaborole is one of these newer agents and was approved by the US Food and Drug Administration in July 2014 for the topical treatment of mild to moderate toenail onychomycosis. Tavaborole is a novel, boron-based anti-fungal agent with greater nail plate penetration than its predecessors, due to its smaller molecular weight. It has proven through several Phase II and III trials that it can be a safe and effective topical agent for the treatment of mild to moderate toenail onychomycosis without the need for debridement. In this paper, we review the landscape of topical and systemic treatment of onychomycosis, with particular attention to the pharmacokinetics, safety, and efficacy of topical tavaborole.