Generalized Multinucleate Cell Angiohistiocytoma: Histopathological and Immunohistochemical Analyses of 10 Lesions.

ABSTRACT: Multinucleate cell angiohistiocytoma (MCAH) is an uncommon fibrohistiocytic disorder that usually presents as a localized solitary papule or multiple grouped papules. Generalized presentation is very rare with less than 20 cases reported in the literature. In this article, we present histopathological and immunohistochemical studies of 10 lesions from a patient with generalized MCAH. In all lesions, the histopathological changes were confined to a discrete zone of the superficial dermis that consisted of (1) an increase in the number of capillary-sized vessels with thickened walls, (2) presence of oval to dendritic spindle cells and stellate hyperchromatic multinucleated cells, (3) fibrosis marked by compact collagen, (4) hypertrophy and hyperplasia of small nerve fibers, and (5) a moderately dense lymphocytic infiltrate. The entire population of the cellular component including the multinucleated cells stained for CD10, whereas a subpopulation of the mononuclear spindle cells stained for factor XIIIa and CD68. CD34 highlighted only the blood vessels. The results confirm that the multinucleated cells lack expression of CD68 and factor XIIIa and that CD10 may be used to highlight the entire cellular component. The rarely reported hypertrophy and hyperplasia of nerve fibers in MCAH may be a common finding as it was observed in all 10 lesions.

Rituximab-Treated Pemphigus Foliaceus in a Schizophrenic Patient: A Challenging Exercise in Diagnosis, Management, and Follow-Up.

Dermatology was consulted in the care of a 58-year-old man with a history of paranoid schizophrenia, neuroleptic malignant syndrome, a positive purified protein derivative test, and a lack of bathing for approximately 4 years who had been admitted to the hospital because of thick, crusted lesions over an increasing portion of his body. Admitted involuntarily, he was disinterested in the history, physical examination, and diagnostic testing. Comorbid schizophrenia presented a unique challenge because he was unable to participate in his care effectively. His story was told through caregivers. Although mostly compliant, the patient was reserved and indifferent, and had little to add even with direct questions.

Striae Distensae: Preventative and Therapeutic Modalities to Improve Aesthetic Appearance.

BACKGROUND: Striae distensae (SD) are aesthetically troublesome to patients and therapeutically challenging. OBJECTIVE: Herein, the authors comprehensively review the literature pertaining to the history, pathogenesis, clinical presentation, clinical rating scales, and laboratory, imaging, and histologic features of SD. METHODS AND MATERIALS: A review of PubMed, MEDLINE, Scopus, Embase, and Google scholar was conducted, including literature published from 1773 to August 6, 2016. RESULTS: The authors identified 68 articles that met inclusion and exclusion criteria. CONCLUSION: There are few randomized controlled trials evaluating the long-term efficacy and safety of various topical and energy-based devices. Based on clinical and anecdotal experience, both nonablative and ablative fractionated lasers have shown modest SD improvement compared with other treatment modalities (including Excimer laser, CuBr laser, pulsed dye laser, and 1,064-nm Nd:YAG laser). In the authors' experience, 1,540-nm nonablative fractionated laser is a worthy first-line modality for the treatment of SD. Future researchers may consider greater focus on enhanced study design, including larger, long-term split-body, or split-SD head-to-head randomized comparative trials with objective outcome measures and end points, such as biopsy and molecular studies demonstrating increased collagen and elastic fibers that correlate to clinical improvement.

Follicular Lymphomatoid Papulosis: An Eosinophilic-Rich Follicular Subtype Masquerading as Folliculitis Clinically and Histologically.

Lymphomatoid papulosis (LyP) is an uncommon CD30 lymphoproliferative disorder with a relatively excellent prognosis. Ten to twenty percent of cases, however, are associated with a lymphoma, typically systemic or cutaneous anaplastic large cell lymphoma, mycosis fungoides, or Hodgkin lymphoma. Subtypes divide LyP into infiltrate-descriptive categories along a spectrum of histological manifestation. Classically, LyP shows a patchy, wedge-shaped, perivascular dermal infiltrate of small- to intermediate-sized lymphoid cells, larger lymphoid, with one, 2, or multiple prominent nucleoli, and a variable admixture of neutrophils, eosinophils, and histiocytes. Follicular LyP shares these characteristics, although its infiltrate is folliculocentric. Variable folliculotropism, follicular dilation, rupture, and mucinosis can occur. This entity is commonly misdiagnosed and underreporting likely because its histopathologic features can masquerade as more common follicular-based entities. The authors present 2 cases of this rare variant to underscore the importance of clinicopathologic correlation in diagnosis. To the best of the authors' knowledge, this is the first report of the follicular LyP variant with concurrent mycosis fungoides. In the context of a literature review, diagnostic pitfalls and classification of this variant are discussed.

Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments.

Disseminated superficial actinic porokeratosis (DSAP) is an inherited disorder of keratinization readily diagnosed through clinical and histologic examination. While generally benign in nature, the lesions can have profound psychosocial implications for patients. Although no cure exists, a number of treatment modalities, from topical medications to laser and light devices, have been reported with variable success. The authors report two cases of DSAP treated with the 1927-nm thulium fiber fractional laser along with a review of the treatment literature for DSAP. This therapy is convenient and safe with nearly no downtime or morbidity associated with pigment or textural changes.

Patient seeking behaviors and online personas: social media's role in cosmetic dermatology.

BACKGROUND: Social media sites, composed of providers, patients, and their social circles, facilitate health and healthcare delivery. OBJECTIVE: To examine patients' perspective on social media as an information source, communication tool, and referral service through an anonymous survey. In addition, influences on patient Internet personas, an actively constructed online identity, around the time of cosmetic procedures are examined. MATERIALS AND METHODS: Patients completed an anonymous institutional review board-approved survey during their initial cosmetic visit. RESULTS: Patients are highly active on social media using it as a multipurpose tool for physician referral services, support groups, and disease education. Patients gathered dermatology information from multiple sources, including friends, family, social media pages, and other online sources, often sharing their own experiences through social media platforms. Patients indicated a desire for provider educational materials on interactive media pages. Most preferred material written by a physician, but some indicated a preference for both physician and lay material. Online images highlighting dissatisfying skin features were influential to select patients, prompting manipulation of online personas and evaluation for aesthetic procedures. LIMITATIONS: Although the study examines cosmetic patient perspectives, data highlight valuable trends for all dermatologists. CONCLUSION: Social media can improve patient education, collaboration, recruitment, and online professional image, leading to healthier patient-centered care.

Respiratory and Perceptual Responses to High-Intensity Interval Exercise in Obese Adults.

PURPOSE: Although high-intensity interval exercise (HIIE) has emerged as an attractive alternative to continuous exercise (CE), the effects of HIIE on ventilatory constraints and dyspnea on exertion have not been studied in obese adults, and thus, tolerability of HIIE in obese adults is unknown. The purpose of this study was to examine differences in respiratory and perceptual responses between HIIE and CE in nonobese and obese adults. METHODS: Ten nonobese (5 men; 24.1 ± 6.2 yr; body mass index, 23.0 ± 1.3 kg·m-2) and 10 obese (5 men; 24.2 ± 3.8 yr; body mass index, 37 ± 4.6 kg·m-2) adults participated in this study. Respiratory and perceptual responses were assessed during HIIE (eight 30-s intervals at 80% maximal work rate, with 45-s recovery periods) and two 6-min sessions of CE, completed below and above ventilatory threshold (Vth). RESULTS: Despite similar work rate, HIIE was completed at a higher relative intensity in obese when compared with nonobese participants (68.8% ± 9.4% vs 58.9% ± 5.6% maximal oxygen uptake, respectively; P = 0.01). Expiratory flow limitation and/or dynamic hyperinflation was present during HIIE in 50% of the obese but in none of the nonobese participants. Ratings of perceived breathlessness were highest during HIIE (5.3 ± 2.4), followed by CEaboveVth (2.5 ± 1.6), and CEbelowVth (0.9 ± 0.7; P < 0.05) in obese participants. Unpleasantness associated with breathlessness was higher in obese (4.2 ± 3.0) when compared with nonobese participants (0.6 ± 1.3; P = 0.005) during HIIE. CONCLUSIONS: HIIE, when prescribed relative to maximal work rate, is associated with greater ventilatory constraints and dyspnea on exertion when compared with CE in obese adults. CE may be more tolerable when compared with HIIE for obese adults.

Combination Tripeptide/Hexapeptide Serum with 1540 nm Nonablative Fractional Laser for the Treatment of Striae Distensae: A Pilot Study.

Striae distensae (SD) are associated with negative psychosocial effects. Improvements have been shown with non-ablative fractional lasers (NAFL). Topical peptides have also been effective in cutaneous rejuvenation; however, no studies have examined combination therapy for striae. Our study evaluated the efficacy and safety of a peri-procedural tripeptide/hexapeptide serum as an adjunct to 1540 nm NAFL for the treatment of SD in 10 patients. All patients reported subjective improvement. The addition of tripeptide/hexapep-tide serum increased the objective improvement, reduced the incidence of post-inflammatory hyperpigmentation, and increased patient satisfaction.

Epidemiologic, Clinicopathologic, Diagnostic, and Management Challenges of Pityriasis Rubra Pilaris: A Case Series of 100 Patients.

IMPORTANCE: Pityriasis rubra pilaris (PRP) is a rare papulosquamous disorder with limited epidemiologic and clinicopathologic data. Little information is available on long-term outcomes, comorbidities, and treatment efficacy. OBJECTIVE: To evaluate objective and subjective disease experience metrics from the perspectives of patients and clinicians. DESIGN, SETTING, AND PARTICIPANTS: One hundred patients with a putative diagnosis of PRP and who elected to participate completed a comprehensive survey, followed by acquisition of their medical records, including histopathology slides and reports. The data were analyzed separately from the health care clinician and the patient perspectives. Two academic dermatologists examined clinical notes, pathology reports, and photographs, confirming diagnoses via predetermined criteria. Patients were categorized into 4 levels of diagnostic certainty to allow stratification of the findings for subgroup analysis. Patients with a diagnosis of PRP were solicited through patient support organization websites. MAIN OUTCOMES AND MEASURES: Clinical outcomes, unexpected association of comorbidities, and efficacy (or lack of it) of various treatment modalities. RESULTS: Among the 100 patients, 50 were diagnosed as having classic, unquestionable PRP. The patients were a median of 61 years old (range, 5-87 years), and 46% were female. Fifty were categorized as level 1 diagnostic certainty, 15 as level 2, 30 as level 3, and 5 as level 4. Of the level 1 patients, 13 (26%) were correctly diagnosed at initial presentation; diagnosis was delayed, on average, by 29 months (range, 0.25-288 months; median, 2 months); and 27 (54%) having undergone 2 or more biopsies. At enrollment, PRP symptoms had persisted in 36 patients (72%) for an average of 58 months (range, 1-300 months; median, 30 months). Thirty-one patients (62%) had comorbidities, including hypothyroidism (20%). Nearly all patients (98%) received some form of therapy. Patients cited topical emollients, corticosteroids, and salicylic acid along with oral retinoids, methotrexate, and tumor necrosis factor inhibitors as most helpful. CONCLUSIONS AND RELEVANCE: Pityriasis rubra pilaris remains a challenging diagnosis without established and specific treatment. Our data highlight new potential avenues for research with therapeutic perspective.