Polypoid amelanotic melanoma: a diagnostic challenge.

Melanoma is a highly aggressive cutaneous malignancy with considerable risk for metastasis. These malignant tumors are typically pigmented given that they arise from melanocytes capable of producing melanin. Amelanotic melanomas are a rare variant and there is often a delay in diagnosis owing to lack of pigmentation. Although there are various presentations of amelanotic melanoma, a solitary polypoid nodule is unusual and warrants further reporting. Herein, we present a patient with a 3-year history of a tender firm, skin-to-pink colored polypoid nodule. Excisional biopsy and work up showed an aggressive amelanotic melanoma with depth of 20mm and nodal metastasis consistent with stage IIIC disease. This case highlights the necessity of recognition and prompt management of this rare subtype of melanoma.

Sexually transmitted diseases.

Sexually transmitted diseases (STDs) continue to be a global epidemic with significant risk of morbidity/mortality for the fetus. STDs with prominent cutaneous findings including condylomata acuminata, genital herpes infections, and syphilis are reviewed. Important clinical cutaneous findings help aid early diagnosis and facilitate treatment. Condylomata acuminata have the potential of causing cervical cancer, anogenital cancer, and oropharyngeal cancer. Significant advances have been made in human papilloma virus vaccinations and treatment. Genital herpes infection can produce significant physical and emotional distress to the patient and significant potential harm to the fetus. Early clinical recognition of STDs and their appropriate management is critical.

Dermatoses of pregnancy.

The dermatoses of pregnancy represent a distinct heterogenous group of cutaneous disorders that can impact the health of the pregnant woman and potentially the fetus. The current classification of pregnancy-specific cutaneous disorders is reviewed, along with important clinical features. Advances in management of these disorders, along with fetal implications, are discussed. The diagnosis of these disorders is challenging, but important clinical features can aid in diagnosis. There have been important advances in the management of these disorders and better understanding of potential fetal risks. Early recognition is critical for appropriate care.

Hair loss in women.

Hair loss is a common cause of morbidity for many women. As a key member of the woman's health care team, the obstetrician/gynecologist may be the first person to evaluate the complaint of hair loss. Common types of nonscarring hair loss, including female pattern hair loss and telogen effluvium, may be diagnosed and managed by the obstetrician/gynecologist. A systematic approach to diagnosis and management of these common forms of hair loss is presented.

Considerations for cutaneous physiologic changes of pregnancy that fail to resolve postpartum.

Pregnancy prompts many adaptive and unique physiologic modifications, with cutaneous changes being possibly the most noticeable. These cutaneous changes are of interest to physicians, since they must be diagnosed as anticipated normal physiologic changes or potentially harmful and managed accordingly. Research has been conducted on physiologically normal and abnormal cutaneous manifestations of pregnancy but is lacking in regard to the persistence of these changes after delivery. This prompts the question as to whether these are normal physiologic changes taking longer to resolve, abnormal changes that may have been previously misdiagnosed, or a separate underlying change that is incorrectly attributed to a common dermatosis caused by pregnancy. Some of the conditions that may persist longer than expected during or after pregnancy, and thus require further workup for an underlying condition, include telogen effluvium, severe hirsutism, palmar erythema, and striae. The objective of this review is to focus on these four common cutaneous physiologic changes of pregnancy, and what to consider when they do not resolve as expected.

Tinea capitis among children in the Columbus area, Ohio, USA.

Tinea capitis is a fungal infection of the hair follicles of the scalp. In the US, the most common organisms have traditionally been Trichophyton tonsurans, and occasionally Microsporum canis. This study was designed to examine patterns of organisms causing tinea capitis and determine factors associated with infection. A retrospective database analysis was conducted to locate records of patients with tinea capitis from May 2001 to May 2006 at Nationwide Children's Hospital in Columbus, OH. Descriptive statistics, frequency analysis, chi-squared test, and Student's t-test were performed to evaluate types of causative organisms and associated patient characteristics. One hundred and eighty-nine charts of patients with a positive scalp culture for tinea capitis were located. Trichophyton tonsurans (88.9%) was the foremost causative agent followed by Trichophyton violaceum (4.2%). Tinea capitis was more prevalent among African Americans and was more common in urban areas (P < 0.05). Children of African descent inhabiting urban settings were most vulnerable to tinea capitis. The most common organism isolated in this retrospective study was T. tonsurans. Trichophyton violaceum and Trichophyton soudanense were also isolated, which are not commonly reported causes of tinea capitis in the US.

The role of Malassezia in atopic dermatitis affecting the head and neck of adults.

Atopic dermatitis is a common chronic skin condition. A subset of patients with head and neck dermatitis may have a reaction to Malassezia flora fueling their disease. Although there are no documented differences in Malassezia species colonization, patients with head and neck atopic dermatitis are more likely to have positive skin prick test results and Malassezia-specific IgE compared with healthy control subjects and patients with atopy without head and neck dermatitis. There is no clear relationship with atopy patch testing. The reaction to Malassezia is likely related to both humoral- and cell-mediated immunity. Clinically, Malassezia allergy may be suspected in patients with atopic dermatitis and: (1) head and neck lesions; (2) exacerbations during adolescence or young adulthood; (3) severe lesions recalcitrant to conventional therapy; and (4) other atopic diseases. There is literature to suggest that these patients will benefit from a 1- to 2-month course of daily itraconazole or ketoconazole followed by long-term weekly treatment.

Bullous pemphigoid precipitated by galantamine hydrobromide.

Bullous pemphigoid (BP) is an acquired autoimmune disease commonly attributed as idiopathic, especially in elderly patients, characterized by subepidermal vesicles and bullae with linear deposits of IgG autoantibodies and complement along the epidermal basement membrane. It also is now commonly accepted that BP can be caused by or associated with drug therapy. We report a case of drug-induced BP (DIBP) likely due to galantamine hydrobromide, a competitive and reversible acetylcholinesterase inhibitor used in the treatment of mild to moderate Alzheimer dementia.

Subcutaneous alemtuzumab for Sézary Syndrome in the very elderly.

Sézary Syndrome (SS) is an aggressive T-cell malignancy often presenting in advanced age and associated with poor prognosis. There is no standard therapy and because of co-morbidities, elderly patients are particularly challenging to treat. Alemtuzumab is an anti-CD52 monoclonal antibody that has activity in SS but is profoundly immunosuppressive, leading to great hesitation about its use in older patients. We treated five octogenarian patients with SS with subcutaneous (SQ) alemtuzumab, at relapse or as initial therapy, for 5-9 weeks. With the exception of transient grade 1-2 hematological toxicity and asymptomatic cytomegalovirus (CMV) (two patients) and Epstein-Barr virus (EBV) (one patient) reactivation, no other toxicities were observed. The clinical and hematological complete response (CR) rate was 100%. Three patients achieved durable responses (8+ to 17+ months). Alemtuzumab was safely administered and showed significant activity in very elderly SS patients.

Metastatic basal cell carcinoma presenting with unilateral upper extremity edema and lymphatic spread.

Basal cell carcinoma (BCC), the most common human malignancy, metastasizes in 0.0028% to 0.5% of cases, usually to the lymph nodes, lungs, bones, and skin. After metastatic spread of BCC, survival averages 1 to 2 years. Chemotherapy, radiotherapy, and surgery are treatment options. We describe metastatic basal cell carcinoma to the skin presenting with unilateral upper extremity edema.

Pruritus in Pregnancy and Its Management.

Pruritus in pregnancy can be a source of significant discomfort in the pregnant patient. Some cases are associated with pregnancy-specific dermatoses, although some patients experience a flare of a preexisting dermatosis. Severe pruritus may be a manifestation of a pregnancy-specific dermatosis associated with increased fetal risks and complications. Early accurate diagnosis and appropriate management are important. Examination often reveals important clinical findings, aiding accurate diagnosis. Pemphigoid gestationis often presents with periumbilical involvement, whereas polymorphic eruption of pregnancy spares the umbilicus and presents in the striae distensae. Intrahepatic cholestasis of pregnancy is associated with intense pruritus of the palms.

Efalizumab-associated thrombocytopenia.

There have been multiple reports of thrombocytopenia associated with efalizumab therapy for the treatment of psoriasis. The current recommendations are to check platelet counts monthly for the first 3 months of efalizumab therapy, then every 3 months for the duration of therapy. We report a case of efalizumab-associated thrombocytopenia that occurred between 10 and 16 weeks after therapy was initiated. Based on our case and a review of the existing reports in the literature, we recommend monthly platelet counts during the first 4 months of therapy, then every 3 months for the duration of therapy. In addition, if the total platelet count drops by 50 x 10(9) cells/L or more between any two consecutive counts, we recommend monthly platelet counts be resumed until the count stabilizes. Finally, patients should be educated about and assessed for the signs and symptoms of thrombocytopenia before starting efalizumab therapy and at every follow-up visit.

Issues affecting specialty career paths in dermatology.

As the field of medicine changes, physicians deal with ever-increasing challenges and pressures. An overview of broad career paths within the specialty of dermatology is presented and important issues affecting these subspecialty tracks are discussed. These issues include increasing regulatory controls, the medical liability crisis, competitive forces, corporate and global outsourcing threats, managed care, and reimbursement.

Magnetic resonance elastography and transient elastography as non-invasive analyses for liver fibrosis: can they obviate the need for liver biopsy in psoriasis patients treated with methotrexate?

The liver biopsy has been regarded as the reference standard method of monitoring hepatic fibrosis in psoriasis patients treated with methotrexate. It has also been subject to concerns over sampling error, internal and external variability, and potential for morbidity and mortality. During the past two decades, two imaging techniques, magnetic resonance elastography and transient elastography, have been developed and approved by the US Food and Drug Administration (FDA) for the assessment of hepatic fibrosis. Although high-quality, psoriasis-specific data are lacking, both methods have been shown to have outstanding efficacy in the detection of hepatic fibrosis, particularly the more advanced stages which may warrant the choice of a therapeutic alternative to methotrexate. Dermatologists should be aware of the availability of these tests and understand their limitations. Prospective studies in psoriasis and methotrexate management using these techniques are needed.

Gender specific association of child abuse and adult cardiovascular disease in a sample of patients with basal cell carcinoma.

OBJECTIVE: The aim of this study is to examine whether child abuse or neglect is more strongly associated with adult cardiovascular disease, and whether these associations differ by gender. METHODS: A total of 116 participants (mean age 57.75 years) reported their experience of childhood maltreatment using the well-validated Childhood Experience of Care and Abuse Questionnaire. Cardiovascular disease was assessed using the Older Adults Resources Survey Multidimensional Functional Assessment Questionnaire. RESULTS: Child abuse but not neglect was significantly associated with adult cardiovascular disease. The significant relationship between child abuse and cardiovascular disease was specific to women. CONCLUSION: The results of this study indicate that being abused as a child is significantly associated with cardiovascular disease in adulthood, particularly among women.

Basal cell carcinoma: stressful life events and the tumor environment.

CONTEXT: Child emotional maltreatment can result in lasting immune dysregulation that may be heightened in the context of more recent life stress. Basal cell carcinoma (BCC) is the most common skin cancer, and the immune system plays a prominent role in tumor appearance and progression. OBJECTIVE: To address associations among recent severe life events, childhood parental emotional maltreatment, depression, and messenger RNA (mRNA) coding for immune markers associated with BCC tumor progression and regression. DESIGN: We collected information about early parent-child experiences, severe life events in the past year as assessed by the Life Events and Difficulties Schedule, depression, and mRNA for immune markers associated with BCC tumor progression and regression from patients with BCC tumors. SETTING: University medical center. PARTICIPANTS: Ninety-one patients with BCC (ages, 23-92 years) who had a previous BCC tumor. MAIN OUTCOME MEASURES: The expression of 4 BCC tumor mRNA markers (CD25, CD3ε, intercellular adhesion molecule 1, and CD68) that have been linked to BCC tumor progression and regression were assessed in BCC tumor biopsy specimens. RESULTS: Both maternal and paternal emotional maltreatment interacted with the occurrence of severe life events to predict the local immune response to the tumor (adjusted P = .009 and P = .03, respectively). Among BCC patients who had experienced a severe life event within the past year, those who were emotionally maltreated by their mothers (P = .007) or fathers (P = .02) as children had a poorer immune response to the BCC tumor. Emotional maltreatment was unrelated to BCC immune responses among those who did not experience a severe life event. Depressive symptoms were not associated with the local tumor immune response. CONCLUSIONS: Troubled early parent-child relationships, in combination with a severe life event in the past year, predicted immune responses to a BCC tumor. The immunoreactivity observed in BCCs and the surrounding stroma reflects an anti-tumor-specific immune response that can be altered by stress.