COVID Community-Engaged Testing in Alabama: Reaching Underserved Rural Populations Through Collaboration.

Rural communities are often underserved by public health testing initiatives in Alabama. As part of the National Institutes of Health's Rapid Acceleration of Diagnostics‒Underserved Populations initiative, the University of Alabama at Birmingham, along with community partners, sought to address this inequity in COVID-19 testing. We describe the participatory assessment, selection, and implementation phases of this project, which administered more than 23 000 COVID-19 tests throughout the state, including nearly 4000 tests among incarcerated populations. (Am J Public Health. 2022;112(10):1399-1403. https://doi.org/10.2105/AJPH.2022.306985).

Clear cell acanthoma.

Clear cell acanthoma is a rarely diagnosed tumor with variable clinical morphology that is usually only recognized by its histopathological features. The primary lesion is a red papule a few millimeters in diameter that often occurs as a single lesion on the lower extremities. In dermoscopy, resemblance of the vessels to a string of pearls is a largely specific finding of clear cell acanthoma. In contrast to the initially uncharacteristic clinical findings, histopathology of clear cell acanthomas is characterized by a typical compact, well-demarcated acanthosis consisting of pale-staining, PAS-reactive keratinocytes. As etiology and pathogenesis are both unclear, nosology of clear cell acanthoma is also controversial, with an ongoing debate as to its classification as cutaneous neoplasia or reactive inflammatory dermatosis.

PET/CT in malignant melanoma: a two-tiered healthcare system? Updated healthcare situation regarding initial staging of malignant melanoma with PET/CT.

BACKGROUND: Patients with stage IIC malignant melanoma are recommended to undergo cross-sectional imaging for initial staging. PET/CT is superior to other methods regarding its diagnostic accuracy of the tumor spread in stage III. So far there is no meaningful data on the nationwide availability, usage and cost recovery of this imaging technique. PATIENTS AND METHODS: Questionnaires on the healthcare situation in 2018 were sent to all German dermatology clinics and PET/CT centers in March and April 2019. RESULTS: 61.2 % of the dermatology clinics (71/115) and 48.2 % of the PET/CT centers (77/160) took part in the survey. A total of 22,645 patients with malignant melanoma were seen in these clinics in 2018. 16.8 % of the patients with stage IIC melanoma received a PET/CT for primary staging. The costs of this examination were covered for all statutory and privately insured patients in 40 % and 68 % of dermatology clinics (20/50 and 34/50), respectively. 68.0 % (34/50) of all dermatology clinics reported relevant changes of treatment according to PET/CT findings. Long examination periods by the health insurance companies and the time required to submit the application were the most common reasons for dermatology clinics to reject a request for PET/CT. Relevant incidental findings were reported in 90.2 % (47/51) of all PET/CT centers. CONCLUSIONS: There are clear differences in the nationwide availability and cost coverage of PET/CT in primary staging for stage IIC melanoma. For these reasons, a two-tiered healthcare system may be assumed.

Lymphomatoid papulosis.

Lymphomatoid papulosis (LyP) is characterized by a varied clinical presentation that includes erythema, papules, pustules, vesicles, plaques, nodules and ulcerations. While its biological course is typically marked by spontaneous regression, the histopathological findings of LyP are consistent with cutaneous T-cell lymphoma. Provided patients do no develop a secondary lymphoma, they exhibit unusually high 10-year survival rates (> 90 %), which is a typical feature of LyP. To date, the etiology and pathogenesis of LyP have not been elucidated. One particular subtype of LyP is known to be associated with chromosome 6p25.3 rearrangement (DUSP22-IRF4 translocation). Treatment is guided by the clinical presentation. In addition to a wait-and-see approach, recommended options include topical corticosteroids and PUVA therapy.

Primary cutaneous diffuse large B-cell lymphoma, NOS and leg type: Clinical, morphologic and prognostic differences.

BACKGROUND AND OBJECTIVES: Primary cutaneous diffuse large B-cell lymphoma, NOS (PCLBCL/NOS) is a rare PCLBCL. Only few data are available for this tumor. The aim of this study was to identify clinical and/or immunohistochemical markers (in addition to Bcl-2) that characterize PCLBCL/NOS, assist in differentiating it from PCLBCL, leg type (PCLBCL/LT) and help to assess the clinical course/prognosis. PATIENTS AND METHODS: Bcl-2- PCLBCL/NOS) cases (n = 14 were compared with Bcl-2+ PCLBCL/LT cases (n = 29). RESULTS: PCLBCL/NOS patients were younger, predominantly male and had better survival rates than patients with PCLBCL/LT. Patients with PCLBCL/NOS presented more often with larger plaques limited to one or two contiguous body regions, whereas PCLBCL/LT cases often presented with disseminated lesions. Neoplastic cells had a higher proliferation rate (Ki67) in PCLBCL/LT patients. The tumor microenvironment of PCLBCL/NOS had a more prominent CD3+ infiltrate. Overall survival data for the whole cohort (n = 37) revealed that female gender and Bcl-2 expression correlated with a worse survival rate. Bcl-6 expression and centroblastic subtype correlated with better outcomes. None of the other markers studied (e.g. GCB/non-GCB subtype) correlated with survival rate. CONCLUSIONS: PCLBCL/NOS and PCLBCL/LT differ in their clinical behavior and outcomes. Bcl-2 still seems to be the best marker for discriminating between these two subgroups. Bcl-2, female gender and Bcl-6 represent prognostic markers for PCLBCL.

Acquired reactive perforating dermatosis.

Acquired reactive perforating dermatosis is characterized by umbilicated erythematous papules and plaques with firmly adherent crusts. Histopathological examination shows a typical cup-shaped ulceration in the epidermis containing cellular debris and collagen. There is transepidermal elimination of degenerated material with basophilic collagen bundles. The etiology and pathogenesis of acquired reactive perforating dermatosis are unclear. Metabolic disorders and malignancies are associated with this dermatosis. Associated pruritus is regarded as a key pathogenic factor. Constant scratching may cause a repetitive trauma to the skin. This pathogenesis may involve a genetic predisposition. The trauma may lead to degeneration of the collagen bundles. Treatment of acquired reactive perforating dermatosis follows a multimodal approach. Apart from the treating any underlying disease, treatment of pruritus is a major goal. Systemic steroids and retinoids, as well as UVB phototherapy are well-established treatment options. Some patients may also benefit from oral allopurinol.

Clinical variants of lichen planus.

Lichen planus is characterized by lichenoid, polygonal papules with fine white lines, called Wickham striae. Lesions most commonly occur on the limbs and on the dorsal aspect of the trunk. At the same time often leukoplakia of mucous membranes as well as nail disorders are seen. There are numerous variants of lichen planus which can be distinguished from the classical form on the basis of morphology and distribution of the lesions. The typical primary lesion of lichen planus may be replaced by other forms, such as patches, hyperkeratoses, ulcerations, or bullous lesions. Moreover, distribution patterns of these lesions may vary and include erythrodermic, inverse or linear arrangements. In contrast to these numerous clinical features, histologic findings remain characteristic in the variants, so that the diagnosis can be made securely. Differential diagnoses of lichen planus include diverse dermatoses such as bullous pemphigoid or paronychia.

Cutaneous and systemic plasmocytosis.

Cutaneous and systemic plasmacytosis is a rare disorder observed mainly in Japanese that features an infiltration of mature plasma cells in various organ systems. In addition to the skin, lymph nodes and bone marrow are regularly affected. Laboratory tests show a polyclonal hypergammaglobulinemia. The cutaneous morphology is characterized by red to dark brown macules, papules and plaques a few centimeters in diameter, usually distributed symmetrically on the face, neck and back. Etiology and pathogenesis are not known. It is speculated that a reactive dysfunction of plasma cells may be triggered by various stimuli, such as interleukin 6. Treatment of cutaneous and systemic plasmacytosis is difficult. A standardized treatment concept does not yet exist. Topical corticosteroids and calcineurin inhibitors are mainly used.

Congenital malalignment of the big toe nail.

Congenital malalignment of the big toe nail is based on a lateral deviation of the nail plate. This longitudinal axis shift is due to a deviation of the nail matrix, possibly caused by increased traction of the hypertrophic extensor tendon of the hallux. Congenital malalignment of the big toe nail is typically present at birth. Ingrown toenails and onychogryphosis are among the most common complications. Depending on the degree of deviation, conservative or surgical treatment may be recommended.

Ramsay Hunt syndrome.

Ramsay Hunt syndrome is defined as herpes zoster oticus associated with an acute peripheral facial nerve paresis and quite often with other cranial nerve lesions. The combination of motor, sensory and autonomic involvement leads to a variety of neurological damage patterns, i. e. facial muscle paresis, hearing and balance disorders, sensory problems and disturbances of taste as well as lacrimal and nasal secretion. Additional variability of the clinical picture of Ramsay Hunt syndrome is produced by varying patterns of skin involvement explained by individual anastomoses between cranial and cervical nerves. Knowledge of these findings and an early diagnosis of Ramsay Hunt syndrome are important as prognosis of cranial nerve damage depends on the time at which acyclovir-corticosteroid therapy is started.

Leukemia cutis - epidemiology, clinical presentation, and differential diagnoses.

Leukemia cutis is an extramedullary manifestation of leukemia. The frequency and age distribution depend on the leukemia subtype. The clinical and morphological findings have a wide range of cutaneous manifestations and may present with nodular lesions and plaques. Rare manifestations include erythematous macules, blisters and ulcers which can each occur alone or in combination. Apart from solitary or grouped lesions, leukemia cutis may also present with an erythematous rash in a polymorphic clinical pattern. Consequently, leukemia cutis has to be distinguished from numerous differential diagnoses, i. e. cutaneous metastases of visceral malignancies, lymphoma, drug eruptions, viral infections, syphilis, ulcers of various origins, and blistering diseases. In the oral mucosa, gingival hyperplasia is the main differential diagnosis. The knowledge of the clinical morphology is of tremendously importance in cases in which leukemia was not yet known.

MAPKinase inhibition after failure of immune checkpoint blockade in patients with advanced melanoma - An evaluation of the multicenter prospective skin cancer registry ADOREG.

OBJECTIVES: Forty to sixty percent of patients with advanced melanoma show primary resistance to PD-1-based immunotherapy, 30-40% of initial responders also progress. Here, we evaluated the outcome of second-line targeted therapy (TT) after progression on PD-1-based immune checkpoint inhibition (ICI) in BRAFV600-mutated melanoma. In addition, we report data on the activity of re-exposure with PD-1-based regimes. METHODS: Patients with advanced (non-resectable stage III or IV, AJCC 2017, 8th edition) melanoma progressing on PD-1-based ICI (nivolumab, pembrolizumab or ipilimumab plus nivolumab) and receiving second-line BRAF plus MEK inhibition were identified from the prospective multicenter skin cancer registry ADOREG. RESULTS: We identified 108 patients with unresectable stage III or stage IV melanoma progressing on first-line ICI (nivolumab, pembrolizumab or ipilimumab plus nivolumab) and receiving second-line combined BRAF/MEK inhibition. Seventy-three percent of the cohort presented with primary PD-1 resistant disease. Median progression-free survival (PFS) on ICI was 2.6 (95% CI 2.2-2.9) months. Median PFS on subsequent TT was 6.6 (95% CI 5.4-7.8) months. Median OS from start of second-line TT was 16.0 (95% CI 11.2-20.8) months. The 3-year PFS and OS rates on second-line TT were 16% and 30%. The objective response rate (ORR) and disease control rate (DCR) to TT were 42.6% and 55.6%. In patients with brain metastases, the ORR and DCR were 31.4% and 43.1%. Patients without brain metastases showed an ORR and DCR of 52.6% and 66.7%, respectively. Response to first-line ICI was associated with a numerically higher ORR and DCR to second-line TT and improved OS on TT. Twenty-three patients received third-line ICI of whom two patients showed an objective response. CONCLUSIONS: BRAF plus MEK inhibition shows meaningful activity and outcome in patients with advanced melanoma resistant to anti-PD-1-based immunotherapy. Rates of long-term benefit and survival in our study were similar to those reported for treatment-naïve patients receiving first-line MAPKi.

Extramammary Paget disease - clinical appearance, pathogenesis, management.

Extramammary Paget disease is a rare malignant neoplasm. With regard to the pathogenesis, two prognostically different forms can be distinguished. The primary form of extramammary Paget disease is an in situ carcinoma of the apocrine gland ducts. In contrast, the secondary form is characterized by an intraepithelial spread due to an underlying carcinoma of the skin or other organ systems. Extramammary Paget disease occurs in older patients. The predilection sites include the entire anogenital skin and less often the axillary region. We present five different patients with this disease, thereby demonstrating its variation in clinical morphology. The lesion usually presents as an erythematous sharply defined spot. The polygonal borders, caused by the centrifugal growth of the tumor, may provide a diagnostic clue. The treatment of choice for extramammary Paget disease remains Mohs' microscopic surgery. However, radiotherapy or topical applications may be alternative treatment options in selected cases. In patients with the secondary form of extramam-mary Paget disease, treatment of the primary tumor is the main approach.

Elastolysis mediodermalis - case report and review of literature.

Elastolysis mediodermalis is a rare disorder typically observed in middle-aged women. Sites of predilection are the trunk and upper arms. The clinical picture varies and may appear as cigarette paper-like wrinkling, perifollicular protrusions or reticular erythema. In contrast to the different clinical morphology, there is a consistent histology, i. e. localized, band-shaped, and rarely focal loss of elastic fibers in the middle dermis. The etiology of elastolysis mediodermalis is unclear. UV radiation or immunological mechanisms may increase the release of matrix metalloproteinases, leading to a degradation of elastic fibers. There is no effective treatment for this condition.

Clinical appearance, differential diagnoses and therapeutical options of chondrodermatitis nodularis chronica helicis Winkler.

The article on chondrodermatitis nodularis chronica helicis summarizes various clinical pictures and differential diagnoses of this entity. This lesion is usually characterized by a solid or cystic nodule but ulcerations or crusts may also occur. The most common differential diagnoses include benign or malignant tumours, which are often confused with chondrodermatitis nodularis chronica helicis. The characteristic pain associated with this condition may serve as an important diagnostic clue in order to rule out other differential diagnoses. The therapy of chondrodermatitis nodularis chronica helices encompasses several conservative as well as surgical treatment options.