The importance of skin exam in chronic pulmonary blastomycosis.

Cutaneous blastomycosis is the most common extrapulmonary manifestation of disseminated blastomycosis, a disease caused by Blastomyces dermatitidis, a dimorphic fungus endemic of North America. Initially, the organism enters the respiratory system by inhalation of the infectious conidia and produces an acute pulmonary infection that may eventually disseminate if it is left untreated. Blastomycosis may represent a diagnostic challenge and its definitive diagnosis requires direct visualization of the distinctive yeast or a positive fungal culture. The objective of this case report is to highlight the importance of the skin exam and tissue biopsy in the diagnosis of blastomycosis. We present a previously healthy patient with chronic pneumonia, evaluated at Pulmonary clinic with non-diagnostic thoracentesis and bronchoscopy, found to have disseminated blastomycosis after biopsy of a scalp lesion in Dermatology clinic.

Urticaria: A comprehensive review: Epidemiology, diagnosis, and work-up.

Urticaria is a common clinical condition presenting with wheals (hives), angioedema, or both. Urticaria has a complex pathogenesis, along with a high disease burden, a significant impact on quality of life, and high health care costs. The first article in this continuing medical education series covers the definition, classification, epidemiology, diagnosis, and work-up of urticaria, taking into account the recent literature and the best available evidence.

Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes.

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H1 antihistamines alone or in combination with other classes of medications, including H2 antihistamines, leukotriene receptor antagonists, or first-generation H1 antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H1 antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).

Trimethoprim-Sulfamethoxazole-Induced Drug Eruption With Eosinophilia and Systemic Symptoms (DRESS).

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe and potentially life threatening adverse drug reaction. To help identify DRESS, several criteria have been established; however, there is still a lack of consensus on diagnosis, and clinical judgment is paramount. Here we describe a 24-year-old female who presented with a cutaneous eruption, fever, lymphadenopathy, eosinophilia, facial edema, and elevated liver enzymes four and a half weeks after a 10-day course of Trimethoprim/sulfamethoxazole (TMP/SMX). We used both the RegiSCAR and J-SCAR criteria to show the validity of classifying this case as DRESS, we also comment on the only other three cases, published to date, that had been reported as TMP/SMX induced DRESS. DRESS can be a difficult diagnosis due to its diverse symptomatology and delayed presentation - therefore, high suspicion and exclusion of other causes is key. Use of validated diagnostic criteria can aid the clinician in this regard. In the absence of a well-established therapy, early recognition, withdrawal of suspected drug(s), and supportive care play a crucial role in the management of DRESS.

J Drugs Dermatol. 2017;16(10):1043-1046.

Topical management and wound care approaches for hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that affects the follicular unit in apocrine glandbearing skin, resulting in deep-seated nodules, sinus tracts, abscesses, and ultimately scarring. HS is a highly distressing condition, and has one of the highest impacts on quality of life compared to other dermatologic diseases. Various topical therapies have been described that may be used alone or in conjunction with systemic or physical modalities for HS. Additionally, proper wound care is essential to the successful management of HS, particularly given the suppurative nature of the disease. However, limited evidence exists regarding the optimal regimen for topical therapy and wound care. On the basis of existing literature, we provide a comprehensive review of topical management and wound care.

Herpes zoster ophthalmicus with associated vasculopathy causing stroke.

Varicella zoster virus (VZV) is an exclusively human, double-stranded DNA virus. Primary infection causes varicella (chickenpox); later the virus becomes dormant in the dorsal root, cranial nerve, and autonomic ganglia along the entire span of the nervous system, retaining the capacity to reactivate and cause a variety of dermal and neurological complications. Recently there has been increasing recognition, both clinically and epidemiologically, of the relationship between VZV and subsequent strokes. Herein, we describe a case of a previously healthy individual with reactivation of VZV causing herpes zoster opthtalmicus along with devastating multifocal vasculopathy. It is crucial for dermatologists to recognize the dermatomal vesicular eruption in this high risk area to aid in prompt diagnosis in an effort to improve clinical prognosis.

Surgical resection of metastatic melanoma in the era of immunotherapy and targeted therapy.

Melanoma is the deadliest form of skin cancer and one of the few malignancies whose incidence is on the rise. The treatment of metastatic melanoma continues to be quite challenging, although in recent years, there has been significant progress. Current National Comprehensive Cancer Network guidelines list immunotherapy, chemotherapy, surgery and clinical trials as potential options for patients with metastatic disease but do not clearly recommend which is superior. Additionally, when utilizing combined modality treatment there are no clear guidelines for the optimal timing of surgery in the treatment of metastatic melanoma. In this paper we sought to compile the current evidence and on-going trials in order to provide a comprehensive review of the different options available and underway in regards to the treatment of metastatic melanoma. It is clear that with the responses now seen with systemic immunotherapies and targeted therapies, an expanded role for surgery is the logical next step.

Dyskeratosis congenita.

IMPORTANCE: Dyskeratosis congenita is a rare disorder that often leads to early death owing to a variety of complications and associated disorders. Early diagnosis and intervention is important in care for patients affected by this disease. OBSERVATIONS: We describe a patient with dyskeratosis congenita (DC) in a child. Our patient had a 3-year history of transaminitis that was felt to be the result of biopsy proven progressive fibrosis of the liver beginning at age 3. He was referred to the dermatology department because of a chronic, evolving eruption with the hope of establishing a unifying diagnosis. Further examination revealed dystrophic nails, numerous dental caries, and blepharitis. Chromosomal analysis on leukocytes showed significant telomere shortening consistent with DC. CONCLUSIONS AND RELEVANCE: Early recognition and long term care is important in patients with DC because of their propensity to develop malignancy, hematologic abnormalities, and infection. Better understanding of this disease may lead to insights into other disorders associated with abnormal telomere maintenance.