Acute and recurrent pustulosis: consolidating uncommon cases of follicular pustulosis induced by UV light and other triggers

There are a growing number of patients with acute and recurrent pustular reactive dermatitis reported without clear parameters to define the entities. Consolidation of cases under the term acute and recurrent pustulosis (ARP) will aid dermatologists in diagnosing such patients in the future.

Objective

Describe the parameters which define acute and recurrent pustulosis and communicate the high predominance for onset in young women based on reported cases.

Methods

PubMed literature search for reports of recurrent follicularly centered neutrophilic eruptions.

Results

According to the clinical characteristics of ARP, 23 patients were identified from prior reports. Interestingly, 20 out of 23 patients were women with a high predominance in early adulthood.

Limitations

This is an understudied and underreported clinical entity. Therefore, limitations include availability of case reports and lack of prior research available on PubMed.

Conclusion

ARP is defined as follicular pustules that occur and remit without treatment and within a week of an identifiable trigger, predominantly affecting women. Consolidating reports of ARP under clear criteria will aid clinical dermatologists in diagnosing this unreported dermatitis.

Identification of a neutrophil-specific PIK3R1 mutation facilitates targeted treatment in a patient with Sweet syndrome

BackgroundAcute febrile neutrophilic dermatosis (Sweet syndrome) is a potentially fatal multiorgan inflammatory disease characterized by fever, leukocytosis, and a rash with a neutrophilic infiltrate. The disease pathophysiology remains elusive, and current dogma suggests that Sweet syndrome is a process of reactivity to an unknown antigen. Corticosteroids and steroid-sparing agents remain frontline therapies, but refractory cases pose a clinical challenge.MethodsA 51-year-old woman with multiorgan Sweet syndrome developed serious corticosteroid-related side effects and was refractory to steroid-sparing agents. Blood counts, liver enzymes, and skin histopathology supported the diagnosis. Whole-genome sequencing, transcriptomic profiling, and cellular assays of the patient's skin and neutrophils were performed.ResultsWe identified elevated IL-1 signaling in lesional Sweet syndrome skin caused by a PIK3R1 gain-of-function mutation specifically found in neutrophils. This mutation increased neutrophil migration toward IL-1β and neutrophil respiratory burst. Targeted treatment of the patient with an IL-1 receptor 1 antagonist resulted in a dramatic therapeutic response and enabled a tapering off of corticosteroids.ConclusionDysregulated PI3K/AKT signaling is the first signaling pathway linked to Sweet syndrome and suggests that this syndrome may be caused by acquired mutations that modulate neutrophil function. Moreover, integration of molecular data across multiple levels identified a distinct subtype within a heterogeneous disease that resulted in a rational and successful clinical intervention. Future patients will benefit from efforts to identify potential mutations. The ability to directly interrogate the diseased skin allows this method to be generalizable to other inflammatory diseases and demonstrates a potential personalized medicine approach for patients with clinically challenging disease.Funding SourcesBerstein Foundation, NIH, Veterans Affairs (VA) Administration, Moseley Foundation, and H.T. Leung Foundation.

The Role of Dermatologists in the Early HIV/AIDS Epidemic: A Historical Review for the 40th Anniversary of HIV/AIDS

In 1981, the HIV/AIDS epidemic was first recognized in young gay men presenting with opportunistic infections and Kaposi sarcoma. Over the past 40 years, there has been an unparalleled and hugely successful effort on the part of physicians, scientists, public health experts, community activists, and grassroots organizations to study, treat, and prevent HIV/AIDS. Yet the role of dermatologists in the investigation of HIV/AIDS and in the treatment of infected patients has largely been neglected in the historical literature. It is important to revisit dermatologists' historic contributions and problematic biases during this epidemic and honor the legacy of the dermatologists who were instrumental in treating and advocating for patients affected by HIV/AIDS.

Long-term use of spironolactone for acne in women: A case series of 403 patients

BACKGROUND

There are limited data regarding the long-term outcomes of spironolactone use for women with acne and its effect on truncal acne.

OBJECTIVE

To comprehensively describe outcomes of patients treated with spironolactone in routine clinical practice, including long-term outcomes.

METHODS

We performed a retrospective case series of 403 adult women treated for acne with spironolactone at an academic medical center between 2008 and 2019. Rates of objective, as assessed by Comprehensive Acne Severity Scale scores, and subjective acne clearance were evaluated, as well as rates of treatment discontinuation, dosage changes, and drug survival. Logistic regression was used to assess for association between incidence of menstrual adverse effects and combined oral contraceptive use.

RESULTS

As evaluated by Comprehensive Acne Severity Scale scores, at the first follow-up, 75.5%, 84.0%, and 80.2% of patients with available data had reduction or complete clearance of acne on the face, chest, and back, respectively. The mean drug survival was 470.7 days. Menstrual adverse effects were less common among those using combined oral contraception (odds ratio, 0.23; 95% confidence interval, 0.11-0.50).

LIMITATIONS

This study was conducted at a single academic medical center.

CONCLUSIONS

Spironolactone improves clinical outcomes and is well tolerated for many adult women with acne using it for an extended duration.

Children of the Sun: a historical look at how pediatric light therapy shaped attitudes and behaviors toward sunbathing

Today, parents are warned to protect their children from the sun's ultraviolet (UV) rays, the most preventable and leading cause of skin cancer. Yet, during the first half of the 20th century, the medical community widely extolled the health benefits of daily sunbaths for babies and children. What initially had begun as evidence-based medical therapies to prevent pediatric diseases, specifically tuberculosis and rickets, soon took on a life of its own as physicians, public health experts, and the general public embraced sunbathing and tanning as a means to ensure health and wellbeing for children and families. Here, we trace how specific medical therapies entered mainstream pediatric medicine and, converging with societal and cultural forces, shaped attitudes and behaviors towards sunbathing that still exist today. Understanding our complex history with the sun may shed light on the current peak of skin cancer incidence and future disease development. Moreover, it may help improve how we educate parents and children about sun safety by taking into account the current social and cultural context of medical practice and health communication.

Update on rosacea classification and its controversies

Rosacea is an inflammatory skin condition that, despite its prevalence, remains imperfectly understood. Without "gold standard" laboratory markers, the diagnosis depends greatly on clinical judgment and the nomenclature used. Throughout the years, the classification schemas for rosacea have changed as clinicians and researchers study the condition. Herein, we highlight the fundamental differences between the proposed classification systems for rosacea, emphasize the areas for improvement, and discuss the implications on clinical decision-making and patient care.

The Association of Age With Clinical Presentation and Comorbidities of Pyoderma Gangrenosum

Importance

Pyoderma gangrenosum is an inflammatory neutrophilic dermatosis. Current knowledge of this rare disease is limited owing to a lack of validated diagnostic criteria and large population studies.

Objective

To evaluate the association of age with the clinical presentation and comorbidities of pyoderma gangrenosum.

Design, Setting, and Participants

This was a multicenter retrospective cohort study performed at tertiary academic referral centers in urban settings. Adults (≥18 years) who were evaluated and diagnosed as having pyoderma gangrenosum at the Brigham and Women's and Massachusetts General Hospitals from 2000 to 2015 and the University of Pennsylvania Health System from 2006 to 2016 were included.

Main Outcomes and Measures

Patient demographics, clinical features, medical comorbidities, and treatment.

Results

Of the 356 validated cases of pyoderma gangrenosum included in the study, 267 (75%) were women and 284 (84.8%) were white. The mean (SD) age at presentation was 51.6 (17.7) years. Pathergy was recorded in 100 patients (28.1%). A total of 238 patients (66.9%) had associated medical comorbidities: inflammatory bowel disease in 146 patients (41.0%); inflammatory arthritis in 73 patients (20.5%); solid organ malignant neoplasms in 23 patients (6.5%); hematologic malignant neoplasms in 21 patients (5.9%); and hematologic disorders, specifically monoclonal gammopathy of undetermined significance, myelodysplastic syndrome, and polycythemia vera in 17 patients (4.8%). When stratified by age, pathergy was more common in patients 65 years or older (36.3% vs 24.3%; P = .02). Inflammatory bowel disease was the only medical comorbidity that was more common in patients younger than 65 years (47.7% vs 26.6%; P < .001), while a number of medical comorbidities were more common in those 65 years or older, including rheumatoid arthritis (13.3% vs 6.2%; P = .03), ankylosing spondylitis (1.8% vs 0%; P = .04), solid organ malignant neoplasms (13.3% vs 3.3%; P < .001), hematologic malignant neoplasms (9.7% vs 4.1%; P = .04), and the aforementioned hematologic disorders (10.6% vs 2.1%; P < .001).

Conclusions and Relevance

Although clinical presentation in this large cohort was similar between different age groups, disease associations varied by age. The findings of this study may allow for a more focused, age-specific evaluation of patients with pyoderma gangrenosum.

Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments

Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.

Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatoses

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The second article in this continuing medical education series reviews the epidemiology, clinical characteristics, histopathologic features, diagnosis, and management of pyoderma gangrenosum as well as bowel-associated dermatosis-arthritis syndrome and the arthritis-associated neutrophilic dermatoses rheumatoid neutrophilic dermatitis and adult Still disease.

Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The first article in this continuing medical education series explores the pathogenesis of neutrophilic dermatoses and reviews the epidemiology, clinical and histopathologic features, diagnosis, and management of Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease.

BAP1: case report and insight into a novel tumor suppressor

BACKGROUND

BRCA1-Associated-Protein 1 (BAP1) is a dynamic tumor suppressor which, when mutated, has been associated with an increased risk of uveal melanoma, cutaneous melanoma, mesothelioma, and several other cancers. Germline BAP1 mutations have been extensively studied, where they have been found to cause hereditary cancer susceptibility. However, their sporadic counterparts, tumors that display a loss of BAP1 expression due to somatically arising mutations in the BAP1 gene, remain a poorly described entity.

CASE PRESENTATION

Here we present the case of a 49-year-old female who presented with an asymptomatic dome-shaped pink papule on the dorsal foot which was found on biopsy to be deficient in the BAP1 tumor suppressor. While the patient's family history did not suggest the presence of a familial cancer syndrome, germline genetic testing was performed and was negative. The patient underwent surgical excision of this sporadically appearing "BAPoma" by Mohs surgery.

CONCLUSIONS

Given the relatively banal clinical appearance of these dome-shaped neoplasms, sporadic BAPomas may often be overlooked by clinicians and dermatologists. In addition to providing a representative case, here we also provide a synopsis of the current understanding of these neoplasms, both in terms of the histopathological features, as well as the molecular mechanisms underlying BAP1 function and its ability to prevent tumorigenesis.

Sweet syndrome in patients with and without malignancy: A retrospective analysis of 83 patients from a tertiary academic referral center

BACKGROUND

Sweet syndrome is a neutrophilic dermatosis that may be categorized into classic, malignancy-associated, and drug-induced subtypes. Few studies have systematically analyzed this rare disorder.

OBJECTIVE

To describe the clinicopathologic characteristics and treatment of Sweet syndrome and identify characteristics associated with concurrent malignancy.

METHODS

We retrospectively reviewed patients with Sweet syndrome at the University of Pennsylvania from 2005 to 2015.

RESULTS

We identified 83 patients (mean age, 57 years; 51% male) with Sweet syndrome: 30% with the classic form, 44% with the malignancy-associated form, 24% with the drug-induced form in the setting of malignancy, and 2% with the drug-induced form. Acute myeloid leukemia was the most common malignancy (in 24 of 83 patients [29%]). Filgrastim was the most common medication (used in 8 of 83 patients [10%]). Leukopenia (P < .001), anemia (P = .002), thrombocytopenia (P < .001), absence of arthralgia (P < .001), and histiocytoid or subcutaneous histopathology (P = .024) were associated with malignancy (χ² test).

LIMITATIONS

This was a retrospective study that represents patients from a single tertiary academic referral center, which may limit its generalizability to other settings.

CONCLUSION

When caring for patients with Sweet syndrome, dermatologists should be aware of the potential association of leukopenia, anemia, thrombocytopenia, absence of arthralgia, and histiocytoid or subcutaneous histopathology with malignancy.

Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013

BACKGROUND

Despite recommendations to limit the use of oral antibiotics and increasing support for hormonal agents in the treatment of acne, it is unclear whether there have been any significant changes in practice patterns.

OBJECTIVE

To characterize changes in prescribing behavior for systemic agents in the treatment of acne in the United States between 2004 and 2013.

METHODS

We conducted a retrospective analysis using the OptumInsight Clinformatics DataMart (Optum, Eden Prairie, MN).

RESULTS

The number of courses of spironolactone prescribed per 100 female patients being managed for acne by dermatologists and nondermatologists increased from 2.08 to 8.13 and from 1.43 to 4.09, respectively. The median duration of therapy with oral antibiotics was 126 and 129 days among patients managed by dermatologists and nondermatologists, respectively, and did not change significantly over the study period.

LIMITATIONS

The OptumInsight Clinformatics DataMart lacks information on acne severity and clinical outcomes.

CONCLUSIONS

Additional work to identify patients who would benefit most from alternative therapies such as spironolactone, oral contraceptives, or isotretinoin represents a potential opportunity to improve the care of patients with acne.

Dermatitis Artefacta

Background:

Dermatitis artefacta (DA) is difficult to diagnose by clinical findings alone. Histopathologic analysis may rule out organic disorders and in some cases establish, in conjunction with microanalytic techniques, a definite diagnosis.

Objective:

We report a young woman with DA in the form of recurrent abscesses whose diagnosis was aided by the identification of subcutaneous foreign material through histologic and microanalytic methods.

Methods:

Histologic examination showed foreign body giant cell reaction with polarizable material, which was identified as cellulose by energy dispersive x-ray analysis and Fourier transform infrared spectrometry.

Results:

Self-injection of exogenous matter was suspected. Referral to an expert in psychodermatology resulted in the diagnosis of multiple psychiatric comorbidities commonly associated with DA. Initiation of antidepressants resulted in marked improvement in her skin disease, as well as her mood and affect.

Conclusion:

We emphasize the importance of interdisciplinary collaboration between dermatologists, dermatopathologists, and mental health professionals in the management of DA.

The history of dermatology at the Woman's Medical College of Pennsylvania

There is little written about the history of women in dermatology. In this paper, we summarize the information obtained from archival records from the Woman’s Medical College of Pennsylvania, one of the first medical schools for women, where several of the early prominent women in dermatology obtained their medical degrees and practiced. Among others, graduates include Rose Hirschler, MD, and Margaret Gray Wood, MD. The school and its graduates made important contributions to dermatology and to the advancement of women in the field. The history of women in dermatology is not well documented, and this historical research provides background in the biographies of pioneering women in an effort to preserve and honor their important work.

Coxsackievirus A6-induced hand-foot-mouth disease

IMPORTANCE

Hand-foot-mouth disease (HFMD) is an acute, self-limited, highly contagious viral illness that commonly affects children younger than 5 years. It is most typically caused by enterovirus 71 or coxsackievirus A16 and results in asymptomatic infection or mild disease. Immunocompetent adults are rarely affected. Recently, there have been increasing reports of a more severe form of HFMD associated with fevers, joint pains, and widespread painful eruptions. Some of these patients required hospitalization for supportive care. These severe cases were most commonly caused by coxsackievirus A6.

OBSERVATIONS

We describe a 37-year-old white man with widespread, crusted, pruritic papules on the scalp, ears, and face and a purpuric and targetoid painful vesicular eruption on his hands and feet, with associated fevers, neurologic symptoms, and arthritis, who required hospitalization for supportive care. His infection with coxsackievirus A6 was confirmed based on polymerase chain reaction from his oral mucosa and cutaneous vesicle fluid.

CONCLUSIONS AND RELEVANCE

Dermatologists should be familiar with the severe variant of HFMD caused by coxsackievirus A6, include it in their differential diagnosis of acute febrile blistering diseases, and be aware that certain patients may require hospitalization.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Lavender

Lavender is a commonly used product in personal and household care items as well as for aromatherapy. It is increasing in popularity as a fragrance. Additionally, multiple recent publications attest to its antimicrobial activity. Whereas lavender has been associated with irritant dermatitis, allergic contact dermatitis, and photodermatitis, it is anticipated that with increasing exposure, more patients will experience these complications. Most cases of allergic contact dermatitis have been reported as being due to occupational exposures through massage and aromatherapy. One study of the Japanese population demonstrated an increased incidence of contact dermatitis from lavender (from 1.1% to 13.9% over 8 years). It is important that clinicians recognize lavender as a potential allergen.

Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan

The incidence of melanoma skin cancer is increasing rapidly, particularly among young women in the United States. Numerous studies have documented an association between the use of indoor tanning devices and an increased risk of skin cancer, especially in young women. Studies have shown that ultraviolet exposure, even in the absence of erythema or burn, results in DNA damage. Countries and regulatory bodies worldwide have recognized the health risks associated with indoor tanning. In the United States, 32 states have passed legislation to regulate the indoor tanning industry, but there is an urgent need to restrict the use of indoor tanning devices at the federal level. The Food and Drug Administration is currently reviewing the classification of these devices. For all of these reasons, the Food and Drug Administration should prohibit the use of tanning devices by minors and reclassify tanning devices to at least class II to protect the public from the preventable cancers and other adverse effects caused by ultraviolet radiation from indoor tanning.