Developing an international standard for the classification of surface anatomic location for use in clinical practice and epidemiologic research.

BACKGROUND: There is currently no universally adopted terminology for defining human surface anatomic location. The lack of precision, accuracy, and reliability of terms used by health care providers, in particular dermatologic surgeons, is unsatisfactory both for epidemiologic research and for high-quality patient care. OBJECTIVE: We sought to create a clinically relevant yet concise surface anatomy terminology for international use including the International Classification of Diseases and to map it to existing disparate terminologies. METHODS: Widely used surface anatomy terminology data sets and diagrams were reviewed. A Delphi consensus convened to create a novel surface anatomy terminology. The new terminology was hierarchically mapped to Systematized Nomenclature of Medicine terms and New York University numbers and physically mapped to 2-dimensional anatomic diagrams for clarity and reproducibility. RESULTS: The final terminology data set contains 519 discrete terms arranged in a 9-level hierarchy and has been adopted by the World Health Organization for the International Classification of Diseases, 11th revision. LIMITATIONS: Specification of most locations requires linking to laterality qualifiers. Fine granularity for larger sites may require the use of additional qualifiers. CONCLUSION: Consistent use of precise and accurate surface anatomy terms is crucial to the practice of dermatology, particularly procedural dermatology. The proposed terminology is designed to form the basis for evolution of a universally adoptable terminology set to improve patient care, interprovider communication, and epidemiologic tracking.

Henoch-Schönlein purpura-like presentation in IgA-dominant Staphylococcus infection - associated glomerulonephritis - a diagnostic pitfall.

BACKGROUND: In children and adults, Henoch-Schönlein purpura (HSP) has a characteristic clinical presentation that includes a purpuric lower extremity skin rash, IgA-dominant glomerulonephritis, and abdominal and joint pain. A similar clinical presentation can be seen in adults who have a systemic infection with methicillin-resistant Staphylococcus aureus. It is critically important to distinguish the IgAdominant glomerulonephritis of HSP from the IgA-dominant glomerulonephritis of staphylococcal infection, because HSP may need to be treated with corticosteroids and immunosuppressives, while Staphylococcus infection-associated glomerulonephritis requires antibiotics. DESIGN: We searched our renal biopsy database for cases of Staphylococcus infection-associated IgA-dominant glomerulonephritis, to identify those with an HSP-like presentation. Their clinical, laboratory, and biopsy findings are reviewed. RESULTS: Between 2004 and 2011, we identified 37 patients with culture-proven Staphylococcus infection-associated glomerulonephritis. Of these, 8 (22%) had an HSP-like presentation manifested by lower extremity purpuric skin rash. Mesangial IgA and C3 deposits were consistent findings on kidney biopsy. Crescents were uncommon. Four of the 8 patients received glucocorticoid (steroid) therapy for a presumed diagnosis of HSP. Renal function worsened in 3 patients, and 1 patient ultimately improved but developed sepsis during the course. Overall, renal outcome was poor in 71% of the cases despite mild chronic renal injury in the biopsy. CONCLUSION: In adult patients with an HSPlike presentation, a high index of suspicion for underlying Staphylococcal infection is warranted. Blood cultures are frequently negative. Cultures from the site of infection should be performed. Steroid treatment did not improve outcomes. Renal outcomes were frequently poor.

Blue foot: a second case of "tattoo blow-out" pigment spread successfully treated with the QS-Nd:YAG laser.

The "tattoo blow-out" phenomenon occurs when tattoo pigments spread outside the border of a tattoo. It is thought to occur when ink is injected too deeply. A healthy 36-year-old female presented to a dermatologist with diffuse spread of tattoo pigment outside the original tattoo that occurred within one day of the placement of a professional tattoo on the dorsum of her foot. The patient was seeking treatment six weeks after the tattoo was placed because she thought the discoloration would improve or resolve on its own, but it worsened. Two punch biopsies were obtained for histology. The biopsy results confirmed granular black pigment consistent with a tattoo in the dermis and subcutaneous fat. The location of pigment was deeper than expected. Due to the success of the QS-Nd:YAG laser in a prior patient, the same treatment was recommended for this patient. The patient received nine laser sessions using the Q-switched laser at 1064 nm, 4 mm, 10 Hz, with gradually increasing energy from 4.5 to 6.0 J/cm2. The pigment outside of the original tattoo borders faded and is barely perceptible. It is important that physicians be made aware of tattoo complications so they can advise patients in regards to the associated risks.

Genome-wide transcriptional profiling of the cyclic AMP-dependent signaling pathway during morphogenic transitions of Candida albicans.

Candida albicans is an opportunistic human fungal pathogen that causes systemic candidiasis as well as superficial mucosal candidiasis. In response to the host environment, C. albicans transitions between yeast and hyphal forms. In particular, hyphal growth is important in facilitating adhesion and invasion of host tissues, concomitant with the expression of various hypha-specific virulence factors. In previous work, we showed that the cyclic AMP (cAMP) signaling pathway plays a crucial role in morphogenic transitions and virulence of C. albicans by studying genes encoding adenylate cyclase-associated protein (CAP1) and high-affinity phosphodiesterase (PDE2) (Y. S. Bahn, J. Staab, and P. Sundstrom, Mol. Microbiol. 50:391-409, 2003; and Y. S. Bahn and P. Sundstrom, J. Bacteriol. 183:3211-3223, 2001). However, little is known about the downstream targets of the cAMP signaling pathway that are responsible for morphological transitions and the expression of virulence factors. Here, microarrays were probed with RNA from strains with hypoactive (cap1/cap1 null mutant), hyperactive (pde2/pde2 null mutant), and wild-type cAMP signaling pathways to provide insight into the molecular mechanisms of virulence that are regulated by cAMP and that are related to the morphogenesis of C. albicans. Genes controlling metabolic specialization, cell wall structure, ergosterol/lipid biosynthesis, and stress responses were modulated by cAMP during hypha formation. Phenotypic traits predicted to be regulated by cAMP from the profiling results correlated with the relative strengths of the mutants when tested for resistance to azoles and subjected to heat shock stress and oxidative/nitrosative stress. The results from this study provide important insights into the role of the cAMP signaling pathway not only in morphogenic transitions of C. albicans but also for adaptation to stress and for survival during host infections.

Interleukin IL-12 blocks a specific subset of the transcriptional profile responsive to UVB in epidermal keratinocytes.

Interleukin-12 (IL-12) is a proinflammatory and immunomodulatory cytokine that plays a critical role it in innate and adaptive immunity by inducing production of interferon-gamma and other cytokines. IL-12 was shown to block the ultraviolet light-induced immunosuppression, important in cancer immunosurveillance, cutaneous allergies and inflammation. To characterize the molecular effects of IL-12 in epidermis we used large DNA microarrays and defined the transcriptional changes in human epidermal keratinocytes 1 h, 4 h, 24 h, and 48 h after treatment with IL-12, as well as in cells treated with both IL-12 and UV light. In keratinocytes, IL-12 activates STAT3 and STAT4; surprisingly, despite activating these transcription factors, the transcriptional effects of IL-12 did not rise above background levels. However, pre-treatment of keratinocytes with IL-12 strongly modulated the transcriptional effects of UV. Pre-treatment with IL-12 enhanced the UV-mediated regulation of 20 and antagonized the regulation of 263 genes. IL-12 enhanced the induction of cytokines by UV. IL-12 antagonized the suppression of cytoskeletal, junctional, metabolic, mitochondrial, and extracellular matrix proteins, while antagonizing the induction of certain signaling proteins and RNA processing enzymes. We conclude that in the epidermis, IL-12 interferes with a specific subset of transcriptional effects of UV irradiation.

Peroxide as a novel treatment for ecchymoses.

Ecchymoses, commonly known as bruises, frequently occur after injury to the skin causes extravasation of red blood cells into interstitial tissue. This extravasation can lead to an inflammatory cascade. The case report presented details one patient who displayed rapid improvement in the pain and appearance of a partially treated bruise on her thigh after an eight-hour application of hydrogen peroxide 15% carbamide gel under occlusion. Hydrogen peroxide 15% carbamide gel may represent a novel treatment for ecchymoses. This potential new treatment for bruises needs to be studied further to detail its adverse effects, safety profile, and efficacy profile.

Systemic contact dermatitis.

Systemic contact dermatitis (SCD) describes a cutaneous eruption in response to systemic exposure to an allergen. The exact pathologic mechanism remains uncertain. The broad spectrum of presentations that are often nonspecific can make it difficult for the clinician to suspect this disease, but it is an important diagnosis to consider in cases of recalcitrant, widespread, or recurrent dermatitis, in which patch testing often reveals allergy to nickel or balsam of Peru. Diagnosis and appropriate management can be life-altering for affected patients. This article on SCD provides an overview of the disease with descriptions of common allergens and some insight into the possible mechanism of action seen in SCD.