Long-term Remission of Pyoderma Gangrenosum, Acne, and Hidradenitis Suppurativa Syndrome.

Pyoderma gangrenosum (PG), acne, and hidradenitis suppurativa (HS)(PASH) syndrome is an autoinflammatory condition that is poorly characterized in the literature, and achieving extended remission has proven difficult. We report the case of a patient with a history of cystic acne and HS who was referred to dermatology for evaluation of refractory PG of 18 months' duration. After therapeutic refinement, remission was achieved and maintained for 4 years using adalimumab and cyclosporine. Treatment success generally is only achieved using multimodal therapies targeting various molecules of the innate immune system, suggesting that PASH syndrome may involve multiple pathways of the inflammatory cascade; however, current understanding of the disease mechanism is scarce. The distinct genotypic and immunologic abnormalities of PASH syndrome require further study to uncover the mechanisms that therapeutic regimens aim to interrupt. Multimodal therapy is necessary to control the autoinflammatory nature of this disease, and further reports of therapeutic successes are essential for advancement in understanding this debilitating condition.

Pleomorphic Dermal Sarcoma With Metastasis to the Lung: A Case Report.

ABSTRACT: Atypical fibroxanthoma and pleomorphic dermal sarcoma (PDS) are dermal malignant mesenchymal tumors that lie at the ends of the same disease spectrum. Clinically indistinguishable from atypical fibroxanthoma, PDS has a more aggressive course with significantly higher rate of local recurrence and metastases. Histological findings that favor a PDS include subcutaneous invasion, tumor necrosis, lymphovascular invasion, and/or perineural infiltration. Herein, we report a case of PDS with metastasis to the lung. Our report highlights the risk of local recurrence and metastatic spread in this cutaneous tumor and the importance of distinguishing this entity from its less aggressive counterpart.

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.

Cannabinoids for the treatment of chronic pruritus: A review.

Medical marijuana is becoming widely available to patients in the United States, and with recreational marijuana now legalized in many states, patient interest is on the rise. The endocannabinoid system plays an important role in skin homeostasis in addition to broader effects on neurogenic responses such as pruritus and nociception, inflammation, and immune reactions. Numerous studies of in vitro and animal models have provided insight into the possible mechanisms of cannabinoid modulation on pruritus, with the most evidence behind neuronal modulation of peripheral itch fibers and centrally acting cannabinoid receptors. In addition, human studies, although limited due to differences in the cannabinoids used, disease models, and delivery method, have consistently shown significant reductions in both scratching and symptoms in chronic pruritus. Clinical studies have shown a reduction in pruritus in several dermatologic (atopic dermatitis, psoriasis, asteatotic eczema, prurigo nodularis, and allergic contact dermatitis) and systemic (uremic pruritus and cholestatic pruritus) diseases. These preliminary human studies warrant controlled trials to confirm the benefit of cannabinoids for treatment of pruritus and to standardize treatment regimens and indications. In patients who have refractory chronic pruritus after standard therapies, cannabinoid formulations may be considered as an adjuvant therapy where it is legal.

The impacts of oral health symptoms, hygiene, and diet on the development and severity of psoriasis.

Numerous studies have suggested a correlation between oral health, the oral microbiome, and various dermatologic conditions, particularly psoriasis. In this study, we utilize a specially designed questionnaire administered to 265 patients at The Ohio State University's dermatology clinics to explore the relationship between psoriasis and a combination of factors that included dietary habits, oral health, and oral hygiene practices. Age, family history of psoriasis, previous diagnosis of strep throat or rheumatoid arthritis, and oral pain or discomfort experienced within the last 12 months were all found to be significant predictors of psoriasis. Additionally, higher body mass index scores, poor gum health, and speech difficulties related to dental problems were all correlated with more severe psoriasis symptoms. Conversely, patients who reported consuming fresh fruit at least once a day experienced milder symptoms. Our goal is to develop a better understanding of how and why psoriasis incidence is correlated with some of the oral health factors under review.

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.

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.

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.

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.

A review of trimethylaminuria: (fish odor syndrome).

Trimethylaminuria, better known as fish odor syndrome, is a psychologically disabling condition in which a patient emits a foul odor, which resembles that of rotting fish. The disorder is most commonly caused by an inherited deficiency in flavin monooxygenase 3, the vital enzyme for the metabolism of trimethylamine, which is the compound responsible for the unpleasant odor. The condition is uncommon, but there has been recent research to suggest that the diagnosis may often be overlooked. Moreover, it is important to be cognizant of this condition because there are reliable diagnostic tests and the disorder can be devastating from a psychosocial perspective. While there is no cure, many simple treatment options exist that may drastically improve the quality of life of these patients. This article will review the literature with an emphasis on the psychosocial impact and treatment options.

A Global Review of Melanoma Follow-up Guidelines.

Early detection of a melanoma recurrence is a major concern for the clinician. However, the follow-up care of melanoma patients lacks a uniform approach. Different dermatological and oncological organizations have developed their own strategies of follow-up management that vary by specialty and methods of screening for recurrence. Some areas of controversy in the follow-up care of melanoma patients include providers of care, use of staging versus Breslow depth to determine follow-up, the role of imaging and laboratory tests, frequency and duration of physical exams, and psychological well-being. Studies have evaluated these aspects of follow-up management, but no consensus exists. However, it is essential for clinicians to collaborate between specialties for an effective, evidence-based approach to melanoma clinical follow-up care.

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.

Generalized eruptive histiocytomas and rosai-dorfman disease presenting concurrently in a patient with myelodysplastic syndrome.

Non-Langerhans cell histiocytoses were originally described as individual diagnoses. However, evidence has been mounting that these entities are manifestations on a spectrum of the same disease. The authors present a patient who initially presented with lymphadenopathy, pancytopenia, splenomegaly, and high-grade fevers. A bone marrow biopsy was performed and she was diagnosed with myelodysplastic syndrome with trisomy 8. Several months later, her persistent pulmonary lymphadenopathy was biopsied revealing Rosai-Dorfman disease. Two years after her initial hospitalization, the patient presented with lesions consistent with generalized eruptive histiocytomas. This case highlights the difficulty that clinicians encounter when trying to separate generalized eruptive histiocytomas, Rosai-Dorfman disease, and the other non-Langerhans cell histiocytoses. While further research needs to be performed in the field of histiocytoses, this case provides clinical support that these diseases are closely linked.