Treatment of selective antibody deficiency with IVIG resulting in decreased frequency of streptococcal infection and improvement of guttate psoriasis.

The association between guttate psoriasis and infection with group A Streptococcus (GAS) has been well established in the medical literature. However, responses to treatments aimed at GAS eradication such as systemic antibiotics or tonsillectomy are inconsistent. Further complicating treatment recommendations for a disease with a suspected microbial trigger, the standard therapy for severe psoriasis is with systemic immunosuppressant medications. This case report illustrates the role of GAS as a trigger for acute onset severe psoriasis in a child whose skin disease initially worsened with a trial of methotrexate. An immune evaluation confirmed a co-existing selective antibody deficiency. Subsequent treatment with intravenous immune globulin dramatically improved his underlying immune function and decreased GAS infections. This improvement in overall immune function and decrease in GAS infections cleared his skin disease. An interval change in formulation to subcutaneous immune globulin was not as effective.

Skin Infections and Outpatient Burn Management: Skin Infections in Patients With Diabetes.

Diabetes is associated with many complications, including foot ulcers. Individuals with diabetes have a 15% to 25% likelihood of developing a foot ulcer in their lifetime. The pathophysiologic mechanisms are multifactorial but the major etiologic factors are peripheral vascular disease and diabetic neuropathy. Foot examinations are recommended at least annually for patients with diabetes to assess the risk of foot ulcers and to detect, diagnose, and manage them. Management includes avoidance of walking, weight-bearing limitation, use of therapeutic footwear, use of dressings and debridement, and antibiotics. Due to immune dysfunction, diabetic neuropathy, and poor circulation, patients with diabetes are at increased risk of other types of infections. These include erythrasma, candidiasis, paronychia, onychomycosis, necrotizing fasciitis, Fournier gangrene, otitis externa, and nontuberculous mycobacterial skin infections. A high index of suspicion is required to diagnose these conditions. Patient evaluation may include a detailed physical examination, imaging, laboratory tests, and biopsies and cultures. Management may involve mechanical or surgical debridement, topical and oral antibiotics, and abscess drainage.

Hidradenitis suppurativa, neutrophilic dermatoses and diverticular disease in a young African-American patient.

Hidradenitis suppurativa (HS) is a chronic skin disorder of the terminal follicular epithelium of apocrine sweat glands, manifesting as painful and exudative papules, pustules, cysts or nodules. This inflammatory condition often presents with other systemic and cutaneous disorders. We present the case of an African-American man with HS who was also diagnosed with neutrophilic dermatoses and diverticular disease. Neutrophilic dermatosis was identified based on histopathology findings. Our patient underwent multiple surgeries for flaring of his skin condition. Colchicine and doxycycline were started, but the patient was not able to tolerate them. Humira was planned for treatment of HS and neutrophilic dermatosis but could not be pursued because of the pericolic abscess. Colonoscopy and radiological investigation revealed multiple colonic diverticuli, for which he initially underwent percutaneous drainage followed by surgical removal of sigmoid mass and colocutaneous fistula. Culture from the specimen revealed abnormal growth of Actinomyces.

Evaluation of the definitions of "high-risk" cutaneous squamous cell carcinoma using the american joint committee on cancer staging criteria and national comprehensive cancer network guidelines.

Recent guidelines from the American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) have been proposed for the assessment of "high-risk" cutaneous squamous cell carcinomas (cSCCs). Though different in perspective, both guidelines share the common goals of trying to identify "high-risk" cSCCs and improving patient outcomes. Thus, in theory, both definitions should identify a similar proportion of "high-risk" tumors. We sought to evaluate the AJCC and NCCN definitions of "high-risk" cSCCs and to assess their concordance. Methods. A retrospective review of head and neck cSCCs seen by an academic dermatology department from July 2010 to November 2011 was performed. Results. By AJCC criteria, most tumors (n = 211,82.1%) were of Stage 1; 46 tumors (13.9%) were of Stage 2. Almost all were of Stage 2 due to size alone (≥2 cm); one tumor was "upstaged" due to "high-risk features." Using the NCCN taxonomy, 231 (87%) of tumors were "high-risk." Discussion. This analysis demonstrates discordance between AJCC and NCCN definitions of "high-risk" cSCC. Few cSCCs are of Stage 2 by AJCC criteria, while most are "high-risk" by the NCCN guidelines. While the current guidelines represent significant progress, further studies are needed to generate a unified definition of "high-risk" cSCC to optimize management.

Specific immunoglobulin isotypes correlate with disease activity, morphology, duration and HLA association in Pemphigus vulgaris.

The molecular basis of disease heterogeneity in autoimmune conditions such as Pemphigus vulgaris is poorly understood. Although desmoglein 3 (Dsg3) has been well established as a primary target of immunoglobulin (Ig) autoantibodies in PV, there remain several questions regarding the overall distribution of anti-Dsg3 Ig subtypes among patient subsets and considerable controversy regarding whether an isotype switch can be observed between phases of disease activity. To systematically address the outstanding questions related to Ig-isotype specificity in PV, we analyzed IgA, IgM, IgG1, 2, 3 and 4 anti-Dsg3 levels by ELISA in 202 serum samples obtained from 92 patients with distinct clinical profiles based on a set of defined variable (activity, morphology, age, duration) and constant (HLA-type, gender, age of onset) clinical parameters, and 47 serum samples from HLA-matched and -unmatched controls. Our findings provide support for earlier studies identifying IgG4 and IgG1 as the predominant antibodies in PV with significantly higher levels in active than remittent patients. We do not see evidence for an isotype switch between phases of disease activity and remission, and both IgG4 and IgG1 subtypes remain elevated in remittent patients relative to controls. We do, however, find IgG4 to be the sole subtype that further distinguishes PV patient subgroups based on different disease morphologies, disease duration, and HLA-types. These data provide further insight into the immune mechanisms responsible for phenotypic expression of disease, and contribute to the broader effort to establish comprehensive immunoprofiles underlying disease heterogeneity to facilitate increasingly specific and individualized therapeutic interventions.