Fragile hands: targeting nonmelanoma skin cancer on older hands using 595 nm pulsed dye laser.

PURPOSE: The mainstay of treatment for nonmelanoma skin cancer (NMSC) on thin skin remains surgical, but procedures on older hands may be complicated by skin fragility and dermal atrophy. Used without cooling, 595 nm (nm) pulsed dye laser (PDL) has the capability of destroying NMSC through nonspecific thermal necrosis. The purpose of this study was to understand recurrence of NMSC on dorsal hands of older patients after one or two treatments using 595 nm PDL. METHODS: A retrospective chart review identified 147 cases of NMSC located on the dorsal hands treated with 595 nm PDL. Cases of basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) were included. All patients received one to two treatments with PDL. The primary outcome was the recurrence of carcinoma. RESULTS: Among NMSC cases treated with PDL, recurrence occurred in 12 patients (8.2%). No cases of BCC recurred during the study period. Recurrence of SCC was 4.7% for SCC in situ and 10.4% recurrence for invasive SCC (p = 0.34). Among 71 patients treated once, recurrence occurred in 10 patients (14.1%), and among 76 cases treated twice, recurrence occurred in 2 patients (2.6%, p = 0.01). CONCLUSION: Two treatments of PDL for NMSC on the dorsal hands of older patients was well tolerated, had low recurrence, and seemed more effective than one treatment.

Sweet syndrome in two children.

We report a 9-month-old girl and a 4-year-old boy with acute febrile neutrophilic dermatosis (Sweet syndrome). Both children were febrile, had leukocytosis, and exhibited lesions characteristic of Sweet syndrome. Both had an antecedent infection. Our evaluation and long-term follow-up of these children failed to reveal evidence of underlying malignancy or a chronic systemic illness typically encountered in Sweet syndrome. Of interest, the 4-year-old boy responded to systemic corticosteroids with remission, whereas the 9-month-old infant experienced flaring of the disease on successive attempts to taper the systemic corticosteroids. Systemic corticosteroid usage was associated with alteration in behavior in the 4-year-old and transient growth retardation in the 9-month-old. In both patients, the adverse effects resolved after discontinuation of the corticosteroids.

Impact of obesity and smoking on psoriasis presentation and management.

OBJECTIVE: To study the impact of obesity and smoking on psoriasis. DESIGN: Cross-sectional study. SETTING: University of Utah Department of Dermatology clinics. PATIENTS: A case series of patients with psoriasis enrolled in the prospective Utah Psoriasis Initiative (UPI) (which carefully performs phenotyping of patients with psoriasis) was compared with 3 population databases: the Behavioral Risk Factor Surveillance System of the Utah population, the 1998 patient-member survey from the National Psoriasis Foundation, and 500 adult patients who attend our clinics and do not have psoriasis (non-psoriatic population). RESULTS: The prevalence of obesity in patients within the UPI population was higher than that in the general Utah population (34% vs 18%; P<.001) and higher than that in the non-psoriatic population attending our clinics. Assessment of body image perception with a standardized diagram in the UPI group resulted in the median body image score of normal weight at 18 years of age and the onset of psoriasis, but it changed to overweight at the time of enrollment in the UPI. Thus, obesity appears to be the consequence of psoriasis and not a risk factor for onset of disease. We did not observe an increased risk for psoriatic arthritis in patients with obesity; furthermore, obesity did not positively or negatively affect the response or the adverse effects of topical corticosteroids, light-based treatments, and systemic medications. The prevalence of smoking in the UPI population was higher than in the general Utah population (37% vs 13%; P<.001) and higher than in the non-psoriatic population (37% vs 25%; P<.001). We found a higher prevalence of smokers in the obese population within the UPI than in the obese population within the Utah population (25% vs 9%; P<.001). CONCLUSIONS: Patients with psoriasis attending the University of Utah Dermatology Clinics were more likely to be obese and to smoke compared with non-psoriatic patients and more likely to be obese compared with other large cohorts with psoriasis. Smoking appears to have a role in the onset of psoriasis, but obesity does not. The high prevalence of obesity and smoking in a psoriasis cohort has not been previously noted; if confirmed, it supports the prediction that a significant portion of patients with psoriasis will have the comorbid conditions and public health issues of those with obesity and smoke.

Refractory Demodex folliculitis in five children with acute lymphoblastic leukemia.

We report five children with acute lymphocytic leukemia on maintenance chemotherapy who had Demodex folliculitis. None experienced complete clearing when treated with permethrin 5% cream. Topical metronidazole helped to lessen the eruption in four, but did not provide full clearing. The one child who was treated with sodium sulfacetamide 10%, sulfur 5% formulation had resolution of the eruption. We suggest that treatment of Demodex folliculitis in children with acute lymphocytic leukemia is more difficult than is suggested in the literature. Newer sodium sulfacetamide/sulfur formulations should be considered when treating this condition, particularly in children with acute lymphocytic leukemia.

Septic, CD-30 positive febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta.

We report life-threatening febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta in an 8-year-old girl. Hemorrhagic-crusted papules and plaques covered over 90% of the patient's body, leaving her susceptible to Pseudomonas aeruginosa and Staphylococcus epidermidis bacteremia as well as Candida parapsilosis fungemia. Sepsis delayed definitive treatment of the underlying cutaneous disease for 2 weeks. Combined therapy with methotrexate and cyclosporin caused remission of the process. Although immunohistochemistry revealed CD-30 positive cells, suggesting the diagnosis of lymphomatoid papulosis, the histopathology was most compatible with pityriasis lichenoides et varioliformis acuta. A partial loss of CD2 and CD5 in the predominant CD3 T-cell lymphocytes suggested a clonal proliferation. Elevated soluble interleukin-2 receptor levels reflected marked T-cell activation, and the downward trend of the levels during treatment coincided with clinical regression of this inflammatory dermatosis.

Vascular stains and hair collar sign associated with congenital anomalies of the scalp.

We reported a series of three meningothelial hamartomas, one benign fibrous tumor, and one aplasia cutis congenita presenting with the hair collar sign and a coexistent vascular stain. Our series highlighted the importance of coexisting cutaneous markers found in the newborn period. The presence of a vascular stain and hair collar sign with or without a congenital scalp nodule should increase suspicion of an associated cranial dysraphism.

Proliferative nodules in congenital melanocytic nevi: a clinicopathologic and immunohistochemical analysis.

Congenital melanocytic nevi (CMN) occur in 1% to 2% of newborns, and the risk of malignant melanoma is increased in patients with large CMN. Appearance at birth or later of a nodular or hyperpigmented area within a CMN simulates malignant melanoma and prompts biopsy. Although their clinical and pathologic features seem ominous, proliferative nodules (PNs) typically are benign and may regress, although atypical features cause greater concern. Here we report clinical and pathologic findings with outcome in 10 children who had multiple biopsies of large CMN with PNs. We reviewed 78 separate samples from the 10 patients and classified the 60 PNs according to published criteria. A subset of 30 samples containing both the CMN and a PNs was analyzed for immunohistochemical reactivity for melanocytic (S-100 protein, HMB45, melan-A), lymphocytic (CD45), cell-cycle/proliferative (Mib-1, p16, p21, p27, c-Myc), apoptotic (p53, Bax, c-kit, CD95), and anti-apoptotic (bcl-2) markers. Both CMN and PNs had similar expression of melanocytic, lymphocytic, and most cell-cycle/proliferative and apoptotic markers, including Mib-1, p16, p21, p27, c-Myc, Bax, CD95, and bcl-2. A greater proportion of PNs than CMN were reactive for p53 (67% vs. 30%, P < 0.0098) and c-kit (97% vs. 3%, P < 0.0001). p53 and p21 expression in CMN and all types of PNs were inversely correlated. When ordinary and atypical PNs were compared, the atypical PNs more frequently expressed p53, Mib-1, Bax, and bcl-2, but less frequently expressed p21. The c-kit expression in nearly all PNs and its absence in nearly all CMN is potentially useful for recognition of PN, suggests a delayed melanocytic maturation process in proliferative nodules, and may be likely indicative of their benign nature. p53 reactivity in concert with a lack of p21 up-regulation by immunohistochemistry suggests that a p53 mutation may be present in PN, although the immunohistochemical findings alone cannot exclude possible overexpression of wild-type p53. Regressive, involutional, or maturational changes were observed in sequential samples from 4 patients. No patient developed malignant melanoma or another melanocytic nevus-associated malignancy during the follow-up period. These findings underscore the similarities between PNs and the underlying CMN and suggest that maturational, proliferative, and apoptotic processes are involved in their clinical evolution.

Seborrheic keratoses: a study comparing the standard cryosurgery with topical calcipotriene, topical tazarotene, and topical imiquimod.

BACKGROUND: Patients with seborrheic keratoses frequently desire an effective topical therapy for seborrheic keratoses. OBJECTIVE: To compare topical calcipotriene, topical tazarotene, and topical imiquimod with standard cryosurgery in the treatment of seborrheic keratoses. METHODS: Fifteen patients with numerous seborrheic keratoses were enrolled in an open-label study comparing cryosurgery with topical agents. Eight separate seborrheic keratoses were selected to be treated with topical medications. One lesion was treated with cryosurgery. RESULTS: One treatment with cryosurgery led to clinical and histological improvement of all lesions treated. Neither scarring nor recurrence resulted in cryosurgery. In seven of 15 patients, tazarotene 0.1% cream applied BID caused clinical improvement in lesions within 16 weeks. CONCLUSION: Cryosurgery produces clinical and histological improvement of seborrheic keratoses. The result with cryosurgery was cosmetically acceptable to all patients. Responders to tazarotene cream 0.1% found it cosmetically acceptable.

Lepromatous leprosy and reversal reaction in a Micronesian immigrant.

A 25-year-old Micronesian man from the island of Otia developed erythematous plaques on his legs. He was diagnosed with erythema nodosum and treated with systemic prednisone. Two months later, he presented with erythematous nodules on his forehead, cheeks, and chin (Fig. 1). Examination revealed scattered violaceous papules on his chest, arms, forearms, hands, and feet, and deep purple macules on his palms and soles. Laboratory evaluation included negative serologies for human immunodeficiency virus, rapid plasma reagin, and hepatitis A, B, and C. Routine histopathology revealed nodular aggregates of histiocytes, plasma cells, and lymphocytes. Histiocytes showed basophilic clusters of organisms within vacuoles, suggesting globi. Acid-fast stain revealed numerous acid-fast-positive rod-shaped organisms. The bacterial index on the Fite stain was four (bacterial index/Ridley's logarithmic scale, indicating 10-100 bacteria/high power field) (Fig. 2). An acid-fast stain obtained from a smear of tissue was positive for acid-fast bacilli, but no acid-fast bacilli were cultured. After the first day of treatment with dapsone 100 mg, rifampin 600 mg, and clofazimine 50 mg, the patient complained of burning and pain in his ankles and wrists. There was intense erythema within the lesions. Edema developed in his hands and feet. Consultation with the Gillis W. Long Hansen's Disease Center in Carville, Louisiana, recommended prompt treatment with corticosteroids. The edema of the hands and wrists was treated as a type I reversal reaction with prednisone 1 mg/kg/day. Subsequently, the edema and neuralgia quickly resolved in his distal extremities.

Aspergillosis in a 24-week newborn: a case report.

Aspergillosis is an uncommon neonatal infection, diagnosed with an increasing frequency over the last two decades. We report a premature neonate who developed aspergillosis while receiving amphotericin B and fluconazole for candidiasis. Despite early recognition and diagnosis, the infant died. We review the clinical appearance of Aspergillus species, the distinctions between primary cutaneous aspergillosis and invasive aspergillosis, and advances in diagnosis and treatment.

Tufted angiomas: variability of the clinical morphology.

In 1989 Wilson Jones and Orkin first described tufted angioma, which has the unifying histologic feature of circumscribed angiomatous tufts and lobules within the dermis. Tufted angioma may take unusual forms clinically. We describe five children less than 3 years of age with tufted angiomas, demonstrating the variability of the morphology of this vascular tumor. Two of the lesions were congenital. Three presented as indurated, vascular-appearing plaques, one of which had associated hypertrichosis. One lesion appeared clinically compatible with a hemangioma of infancy, but continued to enlarge after the child was 32 months old. The remaining lesion was a nearly circumferential, soft tissue tumor of the left forearm with tortuous vessels and a smaller overlying vascular stain. All of these lesions demonstrated the characteristic histology of tufted angioma. The clinical and histopathologic differential diagnosis as well as treatment options for tufted angioma are reviewed.

Annular elastolytic giant cell granuloma.

Annular elastolytic giant cell granuloma is a granulomatous process that presents as slowly growing annular papules and plaques on sun-exposed skin. It was first described in patients in the fourth and fifth decades of life. These lesions are primarily distributed on the head and neck. A review of the literature shows a preponderance of cases in adults. We report two cases of annular elastolytic giant cell granuloma developing in children under the age of 11 years.