Bleeding complication following a shave biopsy in a patient taking ibrutinib.

Ibrutinib is an oral Bruton tyrosine kinase inhibitor approved for use in patients with B-cell malignancies and has been shown to increase progression-free survival in patients with chronic lymphocytic leukemia (CLL). Ibrutinib is known to increase bleeding risk in patients with CLL. We report a patient with CLL on ibrutinib who experienced significant and prolonged bleeding after a routine superficial tangential shave biopsy for suspected squamous cell carcinoma. This prompted temporary cessation of this medication for the patient's subsequent Mohs surgery. This case demonstrates the possible severity of bleeding following routine dermatologic procedures. It is important to consider holding the medication prior to planned procedures such as dermatologic surgery.

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.

BACKGROUND: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data. METHODS: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic. RESULTS: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone. LIMITATIONS: Selection bias and single-center nature. CONCLUSIONS: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

Focal Dermal Elastosis: A Proposed Update to the Nomenclature.

Late-onset focal dermal elastosis is a clinical mimic of pseudoxanthoma elasticum that lacks associations with systemic disease. Although initial reports asserted that the disorder occurs only in the elderly, a growing body of case reports document cases in patients as young as 39 years. We present a case of a 59-year-old woman with this disorder. To reflect the broad age range of patients affected by this disorder, we propose the term "focal dermal elastosis."

Addressing the average lifespan of skin diseases is critical to good patient care.

Dermatology patients routinely ask how long their skin condition may last, yet this critical aspect of their care has not been emphasized in the literature. When a given diagnosis may be self-limited, it is essential that clinicians meet patient expectations by properly discussing the possible time course for resolution. Furthermore, being aware of, and prioritizing the knowledge of the duration of a skin disease can help limit continued exposure to side effects of prescribed treatments once the condition may have self-resolved or remitted.

Ipilimumab-associated halo-like inflammatory reactions around nevi during therapy for metastatic melanoma.

Ipilimumab is an immune-modulating drug that is being used today for various cancers including metastatic malignant melanoma. Owing to its mechanism of action, several adverse events have been reported, including some affecting skin. In this work, we report a novel display of multiple ipilimumab-associated halo lichenoid reactions surrounding benign nevi during treatment of metastatic melanoma. A patient underwent treatment with ipilimumab for treatment of stage IIIC melanoma at our center and was monitored for progress and adverse events throughout treatment. During treatment with ipilimumab, the patient clinically developed multiple halo lichenoid reactions surrounding previously present nevi, which histopathologically showed a lichenoid interface dermatitis associated with the mildly atypical nevi and ill-formed granulomata within the infiltrate. Therefore, ipilimumab may be associated with halo lichenoid reactions surrounding benign nevi and this adverse effect should be added to the various dermatologic reactions that patients can develop while being treated with this agent.

Superficial morphea: case report, look-alikes, pathogenesis, and treatment.

Superficial morphea, a rare variant of morphea, is characterized by hypopigmented to hyperpigmented skin lesions located predominantly in a symmetric fashion at intertriginous sites. These patches and plaques typically lack the significant induration, contractures, and atrophy seen in other subtypes of morphea. Histologic examination is key for accurate diagnosis considering the number of similar conditions which may clinically mimic superficial morphea. Herein, we present a case of a 25-year-old woman who re-presented for consultation in our clinic after gradual progression of her skin lesions. In addition, we review dermatologic look-alikes, as well as the pathophysiology and treatment options for superficial morphea.

Disseminated cutaneous Curvularia infection in an immunocompromised host; diagnostic challenges and experience with voriconazole.

An increasing spectrum and number of opportunistic fungal pathogens have been reported to cause disease in humans over the past decade. Disseminated phaeohyphomycoses caused by rare dematiaceous molds in immunocompromised patients have a high mortality rate and are increasingly reported in the literature. Early diagnosis of disseminated phaehyphomycosis is critical especially in neutropenic patients but can be hindered by the low sensitivity of fungal blood cultures and low clinical suspicion. Cutaneous manifestations are often the earliest sign of disease and conducting a thorough skin exam in febrile neutropenic patients can lead to more rapid diagnosis and initiation of treatment. PCR amplification and sequencing of mold RNA extracted from paraffin-embedded tissue can be useful for diagnosing rare fungal infections when negative fungal cultures preclude morphologic diagnosis. Effective treatment for disseminated phaehyphomycosis is lacking and there is a need to report experiences with the use of newer antifungals.

Zoon's balanitis.

Zoon's balanitis, is typically found in older, uncircumcised males and can be asymptomatic, pruritic, or cause dysuria. The typical appearance is erythematous, discrete, moist plaques with a "cayenne pepper" speckled appearance and an orange hue on the glans penis and sometimes prepuce, which may display "kissing lesions" on areas that are in direct contact with the lesions.These may eventually erode and leave a "rusty stain". Histologically, these have a dense lichenoid infiltrate in the upper and mid dermis with abundant plasma cells.

Atypical blastomycosis in a pregnant woman.

Blastomycosis is a rare fungal infection that frequently involves the skin. Atypical presentations are important to identify, especially in pregnant patients, to initiate appropriate therapy and prevent complications. Uniquely, we describe a case of atypical blastomycosis that presented with painful cutaneous abscesses in a pregnant patient, with dissemination to the central nervous system. The case was successfully treated with liposomal amphotericin B transitioned to voriconazole after delivery without complications for the patient or fetus.

Powerlifter's purpura: a valsalva-associated phenomenon.

The causes of purpura can be classified into intravascular, vascular, and extravascular mechanisms. We describe a case of cervicofacial purpura in a powerlifter attributed to the accompanying Valsalva-associated increased arterial pressure. Powerlifting should be added to the list of activities that may cause purpura.