Predictive value of basal cell carcinoma biopsies with negative margins: A retrospective cohort study.

BACKGROUND: Pathology reports of basal cell carcinoma (BCC) biopsies often contain comments of positive or negative margins, with only 1%-2% of the margin evaluated. The negative predictive value (NPV) of biopsy margin status on residual BCC is unknown. OBJECTIVE: The purpose of this study was to determine the NPV of BCC biopsy margin status on the absence of residual BCC in the corresponding excision. METHODS: From our institution's archives, we collected BCC biopsies with negative margin readings that had subsequent excisions. For excisions read as negative for residual BCC, the excision blocks were sectioned at 150-µm intervals until exhausted. RESULTS: We collected 143 cases that met criteria; 34 (24%) were found to contain residual BCC in the corresponding excision leading to a NPV of 76%; in 31 of 34 (91%) of these cases, the residual histologic subtype was superficial. LIMITATIONS: Our sectioning technique did not evaluate 100% of the excision specimens. CONCLUSION: Negative margins in a BCC biopsy are a poor predictor of residual disease in the patient. We recommend that clinicians treat these lesions, and that pathologists who comment on margin status of BCC biopsies consider adding a caveat to reflect these findings.

Notes from the Field: Outbreak of Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6 Among Basic Military Trainees - Texas, 2015.

On July 7, 2015, a man aged 22 years reported to sick call during basic military training at Lackland Air Force Base (AFB), Texas. He had erythematous, crusted papulovesicular lesions on the extensor surfaces of the upper and lower extremities. The patient was afebrile and otherwise well, and was evaluated later that day by the dermatology service. A viral infection was considered most likely because of the patient's age, absence of fever or constitutional symptoms, and the distribution and morphology of the lesions. The initial differential diagnosis included Henoch-Schönlein purpura, parvovirus B19, and Rocky Mountain spotted fever. However, the clinical signs, including the unique morphology and distribution of grouped vesicles and papules was suggestive of hand, foot, and mouth disease (HFMD), although the patient did not have oral lesions and reported no contact with another person with HFMD. A viral culture and punch biopsy of one of the lesions were obtained.

Shaving Waivers in the United States Air Force and Their Impact on Promotions of Black/African-American Members.

INTRODUCTION: Regulations of the United States Air Force (USAF) prohibit male members from growing beards. Shaving waivers can be issued to airmen who are not able to shave due to various medical conditions such as pseudofolliculitis barbae, a condition that predominantly affects Blacks/African-Americans. Beard growth has been anecdotally associated with a negative impact on career progression. This study sought to establish if shaving waivers are associated with delays in promotion and, if present, if this association leads to racial bias. MATERIALS AND METHODS: An online survey that collected information relating to shaving waivers and demographic data was emailed to all air force male members at 12 randomly selected air force bases. Generalized linear models were conducted to test the waiver group difference in promotion time controlling for rank and the covariates of race/ethnicity, level of education, professional military education completion, and disciplinary action. RESULTS: A total of 51,703 survey invitations were emailed to members, and 10,383 complete responses were received (20.08% response rate). The demographics of the study cohort closely matched that of the USAF. Shaving waivers were associated with a longer time to promotion (P = .0003). The interaction between race and waiver status was not significant, indicating that shaving waivers are associated with a similarly longer time to promotion in individuals of all races. However, 64.18% of those in the waiver group were Black/African-American despite only being 12.85% of the study cohort. CONCLUSIONS: This study found an association between shaving waivers and delayed promotions. The majority of the waiver group was Black/African-American, which may lead to a racially discriminatory effect of the male grooming standards of the USAF.

Therapeutic options to decrease actinic keratosis and squamous cell carcinoma incidence and progression in solid organ transplant recipients: a practical approach.

BACKGROUND: Solid organ transplant recipients (SOTRs) have a 50 to 250 times greater risk of squamous cell carcinoma (SCC) than the general population and experience higher rates of invasive and metastatic disease. These greater risks are a product of the tumorigenic effects of their immunosuppressive medications. As the number of transplantations and the life expectancy of SOTRs increase, SCCs are becoming a major source of morbidity and mortality. OBJECTIVE: To present a practical approach for busy practicing clinicians to the care of SOTRs who are developing SCCs. Topics include assessment and treatment of new and neglected SOTRs; the dermatologist's role with the transplantation team; and practical considerations in the choice of topical agents, systemic agents, and immunosuppressive therapy manipulation. METHODS AND MATERIALS: An extensive literature search of the understanding of SCC pathophysiology and treatment in SOTRs was conducted. RESULTS: Presented here is a logical, concise guide to the care of SOTRs who are developing actinic keratoses and SCCs. CONCLUSION: Proper assessment of patients, understanding therapeutic alternatives and their application, and early institution of preventative and adjuvant therapies can help to decrease skin cancer-related morbidity and mortality in SOTRs.

Deep cutaneous Trichosporon asahii infection in a patient recovering from toxic epidermal necrolysis.

Patients with toxic epidermal necrolysis, a condition that causes full thickness epidermal necrosis that affects over 30% of the skin surface and mucosal membranes, often develop comorbid infections throughout the recovery of the disease [1]. While most commonly these are related to a bacterial source, infections due to viral, mycobacterial, and rarely fungal organisms occur. We present a case of a patient who developed a deep cutaneous fungal infection caused by Trichosporon asahii and discuss the management.

Amyopathic necrotizing dermatomyositis secondary to an underlying malignancy: a case report and review of the literature.

We describe a patient with amyopathic dermatomyositis (DM) secondary to an unusual malignancy. Although the association between amyopathic DM and malignancy has been established, our case report is unique in that the patient exhibited necrotic lesions on her skin. Furthermore, histopathologic examination of the skin lesions demonstrated a combination of epidermal findings typical of DM in addition to a necrotizing, paucicellular vasculopathy. The first indication of an underlying malignancy in this patient was the clinical findings of DM. Prompt identification of such findings may assist in the diagnosis and treatment of the associated malignancy.

Cutaneous Leishmaniasis in a Saudi Arabian Soldier Stationed in the United States.

BACKGROUND: Leishmaniasis is a common parasitic disease seen in many parts of the world, especially in areas where current U.S. and international forces are deployed. Approximately 350 million people are thought to be at risk of cutaneous leishmaniasis (CL) with an annual incidence of 1.5 million cases. Over 90% of cutaneous infections with Leishmania occur in the Middle East, Brazil, and Peru. Outbreaks of CL may occur in military personnel deployed to endemic areas. Since the incubation period for symptomatic CL ranges from weeks to months, symptoms may not appear until well after returning to the United States. As operations continue to expand globally, the exposure and concern for leishmaniasis persists for military physicians. We describe localized CL in a previously healthy male in an effort to help medical personnel identify leishmaniasis on the basis of cutaneous lesions alone, as well as increase diagnostic suspicion when treating patients in nonendemic areas. RESULTS: A previously healthy 30-year-old Saudi Arabian male presented to the emergency department with a 1-month history of four well-demarcated nonhealing, painless ulcers on his left ear, hand, and foot. Symptoms began shortly after arriving in the United States. He had been treated with trimethoprim/sulfamethoxazole, oral clindamycin, mupirocin ointment, and vancomycin for suspected infection without improvement of lesions. Upon presentation to dermatology, physical examination revealed a firm erythematous plaque with central ulceration on his left ear. Two shallow indurated ulcers were also found on his left fourth dorsal finger and left dorsal foot. Biopsy of the foot revealed granulomatous inflammation with predominantly lymphoplasmacytic infiltrate and multinucleated giant cells. Parasitized histiocytes were identified on hematoxylin and eosin stain and focally on Giemsa stain. Polymerase chain was consistent with a diagnosis of leishmaniasis and outpatient treatment was initiated with fluconazole 200 mg daily for 6 weeks. At 2-week follow-up, lesions were noted to be stabilized. DISCUSSION: CL has a wide variety of presentations. The classic lesion appears as a papule that will enlarge, often developing into a nodule or plaque-like lesion with central ulceration. The lesion may be covered with an eschar or by fibrinous material. This presentation can mimic many disease processes resulting in an extensive differential diagnosis that includes bacterial, fungal, and viral infections, cutaneous malignancy, and insect bites. The clinical course, treatment options, response to therapy, and prognosis are all highly variable and dependent on the causative species. Local therapy options, oral systemic agents, and parenteral agents have all shown varying results in the treatment of leishmaniasis. The difficulty with standardizing treatment options for CL stems from the lack of well-controlled studies and the lack of standardized outcome measures. This deficiency in comparative studies of treatment hinders consensual recommendations. However, the choice of the correct therapy often depends on the experience of the clinician, burden of disease, preferences of patients, and cost-effectiveness considerations for the patient and/or the health care system.

Bullous pemphigoid treated with intravenous immunoglobulin.

Bullous pemphigoid (BP) is a blistering autoimmune disease that primarily affects elderly patients who commonly present with comorbidities. Side effects from long-term treatment with conventional cytotoxic and immunosuppressive agents may increase morbidity and mortality in this patient population. We present a case of BP in a 78-year-old woman with an active pulmonary Mycobacterium avium-intracellulare complex (MAC) infection that precluded the use of systemic corticosteroids or other immunosuppressants. Our patient was successfully treated with intravenous immunoglobulin (IVIG) monotherapy, which may provide an alternative treatment option for BP patients who are unable to tolerate cytotoxic or immunosuppressive therapies.

Primary localized cutaneous nodular amyloidosis of the feet: a case report and review of the literature.

Primary localized cutaneous nodular amyloidosis (PLCNA) is a rare disorder that manifests as the cutaneous formation of nodules composed of light-chain amyloid. Although the type of amyloid deposit is similar to primary systemic amyloidosis, there seems to be little, if any, crossover between the 2 diseases. Because reports of PLCNA are sparse, there is no established protocol for treating this disease. This case report presents a 42-year-old man with a visually striking presentation of PLCNA on both feet with some of the lesions possibly being secondary to trauma, a rare phenomenon. The lesions had been present for more than 4 years, and there were no signs or symptoms of systemic amyloidosis. The lesions responded well to a combination of complete curettage followed by CO2; laser ablation. Primary localized cutaneous nodular amyloidosis is rare and difficult to treat, with high rates of recurrence and a concern for progression to systemic amyloidosis. The diagnosis, workup, treatment, and monitoring of PLCNA also are discussed.

Manganese oxidation state as a cause of irritant patch test reactions.

BACKGROUND: Manganese chloride (MnCl2) 2.5% is included in the extended metals patch test series to evaluate patients for contact hypersensitivity to this metal salt. OBJECTIVES: The objective of this study was to prospectively determine the rate of allergic and irritant patch test reactions to MnCl2 (Mn(II)), Mn2O3 (Mn(III)), and KMnO4 (Mn(VII)) in a cohort of patients undergoing patch testing. METHODS: Fifty-eight patients were patch tested with MnCl2, Mn2O3, and KMnO4, each at 2.5% in petrolatum. Patch readings were taken at 48, and 72 or 96 hours, and scored using standard methods. Cultured monolayers of keratinocytes (KCs) were exposed to MnCl2, Mn2O3, and KMnO4 in aqueous culture medium, and cell survival and cytokine release were studied. CONCLUSIONS: MnCl2 caused irritant patch test reactions in 41% of the cohort, whereas Mn2O3 and KMnO4 caused a significantly lower rate of irritant reactions (both 3%). No allergic morphologies were observed. Similarly, in cultured KC monolayers, only MnCl2 was cytotoxic to KC and induced tumor necrosis factor α release.The oxidation state of manganese used for patch testing affects the irritancy of this metal salt, as Mn(II) caused an unacceptably high rate of irritant reactions in a cohort of patients. In vitro studies confirmed these clinical data, as only Mn(II) was cytotoxic to cultured monolayers of KC.

Spread of vaccinia virus through shaving during military training, Joint Base San Antonio-Lackland, TX, June 2014.

Although naturally occurring smallpox virus was officially declared eradicated in 1980, concern for biological warfare prompted the U.S. Government in 2002 to recommend smallpox vaccination for select individuals. Vaccinia, the smallpox vaccine virus, is administered into the skin, typically on the upper arm, where the virus remains viable and infectious until the scab falls off and the epidermis is fully intact - typically 2-4 weeks. Adverse events following smallpox vaccination may occur in the vaccinee, in individuals who have contact with the vaccinee (i.e., secondary transmission), or in individuals who have contact with the vaccinee's contact (i.e., tertiary transmission). In June 2014 at Joint Base San Antonio-Lackland, TX, two cases of inadvertent inoculation of vaccinia and one case of a non-viral reaction following vaccination occurred in the security forces training squadron. This includes the first reported case of shaving as the likely source of autoinoculation after contact transmission. This paper describes the diagnosis and treatment of these cases, the outbreak investigation, and steps taken to prevent future transmission.