Viral folliculitis

Viral folliculitis is an infrequently reported entity. We describe two patients with viral folliculitides, including a case of herpetic sycosis caused by herpes simplex (HSV) and a case of herpes zoster (HZ) without blisters. Clinicians should consider viral etiologies in the differential diagnosis of superficial infectious folliculitis, especially those cases refractory to antibacterial or antifungal therapy.

Painful red nodules of the legs: a manifestation of chronic infection with gram-negative organisms

Skin infection secondary to gram-negative organisms is uncommon and is typically limited to persons who are immunocompromised. When these do occur, they are acute, progressive, and severe. Here we report 2 cases of painful red nodules that presented with a waxing and waning course over a long period. One case is that of a 45-year-old healthy white man who developed Serratia marcescens infection in 1 leg. The other case is that of a 78-year-old man with chronic lymphocytic leukemia treated with prednisone who developed infection of the leg secondary to Pseudomonas aeruginosa. In the first case, symptoms were present for 2 years before definitive diagnosis and treatment. In the second case, 4 months elapsed. Ultimately, both patients responded to antibiotic therapy and recovered. These cases illustrate an unusual presentation of chronic red painful nodules of the leg secondary to infection with gram-negative organisms and underscore the importance of culture even when infection seems unlikely.

Cutaneous manifestations of cancer

The appearance of skin lesions in patients with occult or obvious malignancy may be of extreme value in the detection and management of cancer because the skin is readily accessible to examination and biopsy. Examination of the skin of our patients can provide important insights into underlying malignant processes or possible complications from cancer treatment. The range of cutaneous abnormalities is wide, and include cutaneous paraneoplastic syndromes such as xanthomas, acanthosis nigricans, carcinoid syndrome, unusual erythematous eruptions such as erythema gyratum repens, and a number of genetic syndromes associated with malignancies and inherited dermatoses.

Erysipeloid sporotrichosis in a woman with Cushing's disease

A woman presented with a swollen red leg of 2 weeks' duration. Culture of the skin biopsy specimen confirmed this to be an infection caused by Sporothrix schenckii. Systemic evaluation led to the diagnosis of Cushing's disease and explained the unusual morphology. Treatment-related complications are also discussed.

Accentuated viral exanthems in areas of inflammation

Types of lesions and patterns of distribution aid in the recognition of viral exanthems. Varicella and hand-foot-and-mouth disease can appear atypically in areas of inflammation. We describe 5 cases of morphologically altered exanthems that localized early and preferentially to areas of inflammation.

On the importance of the clinician-educator. Dermatology fellowship for academic clinician teachers

Within each academic dermatology department there usually exists one clinician who is viewed as the "gold standard" against which diagnostic and therapeutic acumen are measured. As a patient with a puzzling disorder is discussed at rounds, it is to this master that the final word falls, whose recommendation for treatment gets the nod; it is to his or her words that people remain quiet and listen intently. They are commonly also the leading teachers in the medical centers, passing on to succeeding generations the factual knowledge, spiced with bits of philosophy, ethics, and anecdote, that helps to ensure the development of dermatology residents into superb practitioners. They are often the ones most responsible for generating medical student interest in our specialty. Such individuals in our current lingo are "clinician-educators," the rock residents depend on to provide role models to emulate in the diagnosis, care, and treatment of our patients and to whom the community looks to for help in caring for their patients with the most difficult diagnoses.

Patterns of X chromosome inactivation in sporadic basal cell carcinomas: evidence for clonality

BACKGROUND

Some basal cell carcinomas (BCCs) contain genetic mutations, suggesting that the lesion is composed of a monoclonal population of cells. Clonality, a distinguishing feature of neoplasia, can be inferred by referencing clonal markers such as the pattern of X chromosome inactivation. The X-linked human androgen receptor gene (HUMARA; GenBank) contains a polymorphic DNA marker that reliably illustrates the pattern of X chromosome inactivation in a tissue.

OBJECTIVE

Our purpose was to determine the clonality of sporadic BCCs by examining patterns of X chromosome inactivation.

METHODS

The patterns of X chromosome inactivation in paired samples of normal skin and sporadic BCCs from 24 women were compared by means of the HUMARA gene assay.

RESULTS

All samples from normal skin displayed random X chromosome inactivation, consistent with lyonization. In 15 of 25 tumor samples (60%), nonrandom X chromosome inactivation was detected, consistent with monoclonality.

CONCLUSION

At least some sporadic BCCs are composed of a monoclonal population of cells, strengthening the contention that a collection of mutations confers a growth advantage to this epithelial lesion.

Allergic contact dermatitis from aromatherapy

Allergic contact dermatitis secondary to aromatherapy has been only rarely reported. We present 39-year-old woman who had used aromatherapy products for approximately 2 to 3 years who presented with an erythematous eruption on her face and chest. Patch testing showed a positive reaction to neomycin and fragrance mix. On cessation of her aromatherapy products, her eruption rapidly resolved. Aromatherapy products containing essential oils may need to be considered as a cause of allergic contact dermatitis because of the increasing popularity of this treatment.

Viral folliculitis. Atypical presentations of herpes simplex, herpes zoster, and molluscum contagiosum

BACKGROUND

Viral folliculitis is an infrequently reported entity. The patients described herein were seen over a 12-year period of practice in a referral dermatologic setting. The cases involve a variety of viral infections limited to the hair follicle.

OBSERVATIONS

We describe 5 patients with a variety of viral folliculitides: 2 with herpetic sycosis caused by herpes simplex; 1 with herpex simplex folliculitis (this patient also had human immunodeficiency virus); 1 with herpes zoster without blisters; and 1 with molluscum contagiosum.

CONCLUSIONS

These 5 cases demonstrate that viral folliculitis has varied causes and presentations. Clinicians should consider viral agents in the differential diagnosis of superficial infectious folliculitis, especially in cases that are refractory to antibacterial or antifungal therapy.

Esophageal Stricture in a Patient with Epidermolysis Bullosa Acquisita: Endoscopic and Medical Management

Background:

This 40-year-old man with extensive and severe epidermolysis bullosa acquisita (EBA) developed an esophageal stricture that caused dysphagia and limited his nutritional intake.

Objective:

The purpose of the evaluation and management was to relieve the symptomatic obstruction so that he could better swallow food and medications.

Methods:

Endoscopic visualization of the stricture allowed for balloon dilation to be effected. The radial forces applied probably allowed for a less traumatic intervention than the linear shearing forces of bougienage.

Results:

The stricture widened and immediately provided less dysphagia and better tolerance in ingesting food. Medical treatment with sucralfate, known to bind to and protect ulcer bases, also improved his symptoms.

Conclusions:

Esophageal strictures are relatively uncommon in patients with EBA; however, when faced with a stricture in this or other scarring bullous diseases that affect the esophagus, endoscopic balloon dilation combined with postprocedure sucralfate offers improvement with advantages over older methods of intervention.

Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial

OBJECTIVE

To assess the effect of white petrolatum vs bacitracin ointment on wound infection incidence, allergic contact dermatitis incidence, and healing characteristics.

DESIGN

Randomized, double-blind, prospective trial comparing white petrolatum with bacitracin ointment in postprocedure wound care.

SETTING

A general outpatient dermatology clinic and a tertiary referral advanced surgical procedure clinic at Walter Reed Army Medical Center, Washington, DC.

PATIENTS

A total of 922 patients who had dermatologic surgery with a total of 1249 wounds.

MAIN OUTCOME MEASURES

The incidence of infection and allergic contact dermatitis during a follow-up period of 4 weeks. Healing characteristics were secondary outcomes.

RESULTS

Of the 922 patients enrolled, 440 in the white petrolatum group and 444 in the bacitracin group were evaluable for clinical response. The 2 treatment groups had comparable baseline characteristics. Thirteen patients developed postprocedure infection (1.5%), 9 (2.0%) in the white petrolatum group vs 4 (0.9%) in the bacitracin group (95% confidence interval for difference, -0.4% to 2.7%; P=.37). Eight infections (1.8%) in the white petrolatum group were due to Staphylococcus aureus vs none in the bacitracin group (P=.004). No patient in the group using white petrolatum developed allergic contact dermatitis vs 4 patients (0.9%) in the group using bacitracin (P=.12). Additionally, there were no clinically significant differences in healing between the treatment groups on day 1 (P=.98), day 7 (P=.86), or day 28 (P=.28) after the procedure.

CONCLUSIONS

White petrolatum is a safe, effective wound care ointment for ambulatory surgery. In comparison with bacitracin, white petrolatum possesses an equally low infection rate and minimal risk for induction of allergy.

Dermatologic formularies in the managed care setting

Formularies and formulary systems are not a new concept in medical practice. In this country, they have been used in selected settings since the Revolutionary War and formal guidelines were published in 1933. They are in essence a collection of prescribing policies of physicians in a particular practice setting. Formularies are administered by a system in which medical staff members working through a pharmacy and therapeutics (P&T) committee recommend, evaluate, appraise, and select drugs to be included in the medication list. The system also develops, maintains, and enforces policies regarding how restrictive the process will be and what methods will be used to ensure compliance and verify that educational and quality standards are met.

Clonality of basal cell carcinoma--molecular analysis of an interesting case

Tumor cells represent a single clone of cells that have undergone a series of mutations in genomic DNA. This process, known as clonal evolution, is a distinguishing feature of cancer. The human androgen receptor gene (HUMARA; GenBank) contains a highly polymorphic cytosine-adenine-guanine trinucleotide repeat that can be used to determine clonality by depicting X chromosome inactivation patterns. Random X chromosome inactivation is consistent with polyclonality; nonrandom X chromosome inactivation indicates a clonal population of cells. Basal cell carcinoma (BCC) demonstrates an atypical growth pattern in that it grows slowly, rarely metastasizes, and is rarely lethal. Whether this tumor results from the accumulation of mutations in a single cell with subsequent clonal expansion or reflects a polyclonal response by a group of cells to a growth stimulus is unknown. To provide further insight into the molecular events characterizing BCCs, we determined the clonal origin of five modular BCCs from a female patient by analyzing X chromosome inactivation patterns at the HUMARA locus. All tumors demonstrated a nonrandom pattern of X chromosome inactivation, consistent with monoclonal proliferation. These findings provide strong genetic evidence that sporadic BCCs develop by clonal evolution and support the contention that a series of mutations in a single cell is responsible for the altered growth state seen in these transformed epithelial cells.