Laser-Assisted Delivery of Topical Cidofovir in the Treatment of Plantar Warts

Recalcitrant plantar warts pose a therapeutic challenge. Cidofovir is a viral DNA polymerase inhibitor that has been used in treatment of verrucae with greater success than traditional treatments in some cases. Laser-assisted drug delivery enhances drug penetration beyond the epidermis and is particularly well-suited, though under-utilized, to target palmoplantar verrucae. We report the use of an erbium:yttrium-aluminum-garnet (Er:YAG) ablative fractional laser (AFL) followed by topical cidofovir in treating recalcitrant plantar warts. Two patients were treated with a 2940-nm Er:YAG laser at depths of 1.2-1.5 mm followed by topical application of cidofovir 75 mg/mL. Both patients exhibited a significant reduction in lesion size and improvement in symptoms. AFL-assisted delivery of topical cidofovir represents a promising therapeutic option for recalcitrant plantar warts. J Drugs Dermatol. 2019;18(7):663-665.

Interrater Reliability of Clinical Grading Measures for Cutaneous Chronic Graft-vs-Host Disease.

Importance: Cutaneous chronic graft-vs-host disease (cGVHD) is common after allogeneic hematopoietic stem cell transplant and is often associated with poor patient outcomes. A reliable and practical method for assessing disease severity and response to therapy among these patients is urgently needed. Objective: To evaluate the interrater agreement and reliability of skin-specific and range of motion (ROM) variables of the 2014 National Institutes of Health (NIH) response criteria for cGVHD and a skin sclerosis grading scale (SSG). Design, Setting, and Participants: In this observational study performed at a single tertiary academic center, 6 academic blood and marrow transplant specialists and 4 medical dermatologists examined 8 patients with diagnosed cutaneous cGVHD on July 10, 2015. The patient cohort was enriched for patients with sclerotic features. Each patient was evaluated by using the skin-specific and ROM criteria of the 2014 NIH response criteria for cGVHD and an SSG ranging from 0 to 3. Each patient was also asked to complete quality-of-life scoring instruments. Interrater agreement and reliability were estimated by calculating the Krippendorff α and Cohen κ statistics. Data were analyzed from September 29, 2015, through November 22, 2018. Main Outcomes and Measures: Estimation of interrater agreement by interclass coefficient (Krippendorff α and Cohen κ statistics) for the skin-specific and ROM components of the 2014 NIH Response Criteria for Chronic GVHD and for the SSG. Results: The median age of the patients evaluated was 54 years (range, 46-58 years). Patients were predominantly male (6 [75%]). Six of the 8 patients had a predominantly sclerotic cutaneous phenotype. Interrater agreement among our experts was acceptable for NIH skin feature score (0.68; 95% CI, 0.30-0.86) and good for NIH ROM scoring (0.80; 95% CI, 0.68-0.86). Dermatologists had acceptable agreement for NIH skin GVHD score (0.69; 95% CI, 0.25-0.82) and skin feature score (0.78; 95% CI, 0.17-0.98), good agreement in ROM grading (0.85; 95% CI, 0.69-0.90), and near perfect agreement in identifying sclerosis (0.82; 95% CI, 0.27-0.97). Conclusions and Relevance: Although dermatologists had acceptable agreement in NIH skin GVHD score and skin features score, near perfect agreement in identifying cutaneous sclerosis, better agreement in grading severity of cutaneous cGVHD, especially in the intermediate grades, appears to be needed.

Nodular amyloidosis in a patient with systemic scleroderma.

Primary cutaneous amyloidosis may be characterized as macular amyloidosis, lichenoid amyloidosis, or nodular amyloidosis. Nodular amyloidosis results from the deposition of immunoglobulin light chains and may rarely be associated with systemic amyloidosis. We report an unusual case of a patient with systemic scleroderma who developed primary cutaneous nodular amyloidosis on the left lower leg. The diagnosis was confirmed with a skin biopsy with Congo red staining and a novel technique using a laser microdissection and mass spectrometry-based proteomic analysis method for amyloid protein characterization. A work-up for systemic amyloidosis was negative and the patient improved symptomatically with wound care. Patients with primary cutaneous nodular amyloidosis should be followed clinically over time for the possible development of systemic amyloidosis, although the risk of disease progression is likely low.

Improving the detection of pressure ulcers using the TMI ImageMed system.

OBJECTIVE: The aim of the study was to evaluate a novel infrared imaging device coupled with an intelligent software interface that may provide a more objective means of identifying anatomical sites at risk for pressure ulcer (PrU) development as compared with the Braden Scale for Predicting Pressure Sore Risk. DESIGN: Repeated-measures design. SETTING: Duke University Medical Center. PARTICIPANTS: One hundred patients admitted to a medical unit at risk for PrUs. MAIN RESULTS: Only 5 participants developed early stage PrUs (Stages I and II). However, the infrared imaging device not only predicted all 5 participants to be at risk, but also predicted the anatomical location where the ulcer would develop. The Braden Scale correctly identified 3 of 5 participants who developed PrUs. It was also determined that a temperature variance of 1.5° C was able to accurately predict PrU development. CONCLUSION: Infrared imaging using intelligent software may become a promising, objective method for identifying incipient PrUs and provide clinicians with specific anatomical locations for increased preventive interventions.

Vibrio vulnificus septicemia and leg ulcer.

Vibrio vulnificus is a gram-negative bacteria that can cause septicemia, wound infection, or a self-limiting diarrhea. This infection typically presents as an extremely virulent infection in patients with underlying liver disease 1 to 2 days after exposure. We report a case of V vulnificus septicemia, cellulitis, and leg ulceration in a patient who had symptoms develop after exposure to brackish water (19 days before admission) or after ingestion of raw oysters (10 days before admission). The longest incubation period previously reported is 6 days. The diagnosis was made from identification of the bacteria from blood cultures. No organisms were seen or grown in culture from the skin biopsy specimen, which showed epidermal necrosis and dermal and subcutaneous neutrophilic abscess. We review 13 cases of V vulnificus septicemia and leg ulcers and their approximate incubation time.