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It can be difficult to delineate the cause of urticarial eruptions, and in chronic cases, it can be a challenging condition to effectively treat. Several forms of urticarial eruptions are well documented and established. Our review focuses on a form of urticaria that is less commonly reported: adrenergic urticaria. In this review, we aim to consolidate the literature in the hopes that this urticarial subtype is considered in urticarial differentials, as well as highlight potential gaps in the research and future directions in treatment options.

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With the rise of Janus kinase (JAK) and Signal Transducer and Activator of Transcription (STAT) inhibitor use in dermatologic conditions, there has been increasing hope in treating extensive and difficult-to-treat inflammatory cutaneous conditions. Today we report a case of oral lichen planus successfully treated with an oral JAK1 inhibitor, upadacitinib. This case had been unresponsive by several standard methods but responded with 70% improvement within 1 month when treated with upadacitinib.  J Drugs Dermatol. 2024;23(4):7859.     doi:10.36849/JDD.7859e  .

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Drug reactions are a known risk in combined anti-cancer therapy. Less commonly recognized risks of chemotherapies and targeted immunotherapies include toxic erythema of chemotherapy reactions. With the immunosuppressive quality of cancer combined with anti-cancer treatments, patients are also susceptible to increased infection. We report a rare case of combined targeted anti-cancer treatment with bevacizumab and lorlatinib, and an associated transformation of an eczematous process into a toxic erythema of chemotherapy vasculitic eruption, with combined malignant intertrigo characteristics and superimposed infection following the initiation of bevacizumab.

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This case report documents the rare finding of argyria limited to the nails secondary to colloidal silver ingestion. We highlight the significance of early detection of argyria secondary to colloidal silver ingestion and offer photos of the subtle changes in the nails that indicate the development of argyria. With the popularity of over-the-counter supplementation, it is important for medical providers to be aware of early signs of argyria, prior to progressive, permanent pigmentary changes.

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Nephrogenic systemic fibrosis (NSF) is a progressive and potentially fatal fibrosing skin disorder found mainly in patients with renal insufficiency. NSF is characterized by thickened and hyperpigmented skin lesions with or without systemic involvement. In essentially all patients, this disease entity has been associated with the administration of gadolinium contrast agents for imaging purposes. Microscopic recognition of this entity remains challenging, as the diagnosis is based on various clinical and histopathologic features that overlap with other fibrosing disorders. No single feature is absolutely specific for NSF. We report a finding of osseous sclerotic bodies with elastin trapping appearing on histopathology in the clinical setting of NSF with hemodialysis-dependent renal failure. Our report of an additional attribute indicative of NSF may aid in making the diagnosis.

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Widely considered the gold standard treatment option for tattoo removal, the use of Q-switched lasers may very rarely result in the formation of large bulla. While very disconcerting to patients, these lesions are easily managed and, with proper care, heal quickly with no long-term consequences. The authors present three cases of patients who had bullous reactions shortly after receiving Q-switched laser treatment of tattoo ink. Bullous formation in all three patients was treated successfully.

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A variety of clinical and histological presentations can accompany the evolution of malignant melanoma. Unusual cytological variants of malignant melanoma include balloon cell, signet ring cell, myxoid and other metaplastic changes. With the exception of a case of pemphigus-like changes associated with malignant melanoma in paraneoplastic pemphigus, acantholysis is not a common histopathological feature of malignant melanoma. We present two unique cases of malignant melanoma with varying degrees of extensive melanocytic discohesion in an acantholytic pattern mimicking pemphigus vulgaris, further referred to in this article as 'discohesive melanoma'. Routine direct immunofluorescence studies for pemphigus-related antibodies (IgG and C3) were negative. In one case, indirect immunofluorescence for desmoglein autoantibodies characteristic of pemphigus were negative, although positive antibodies to desmoglein 1 was detected using immunosorbent assay. The differential diagnoses and pitfalls in recognition of this unusual presentation of malignant melanoma along with possible pathogenetic mechanisms are discussed.

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BACKGROUND: As tattoos have become increasingly popular in the Western world, tattoo-removal requests have also increased, as patients' personal identities advance. Laser tattoo removal is the current treatment of choice given its safety and efficacy. However, due to varying types of tattoos, it has been difficult to quantify the number of laser treatments required with certainty when discussing laser tattoo removal with our patients. OBJECTIVE: To propose a practical numerical scale to assess the number of laser tattoo-removal treatments necessary to achieve satisfactory results. METHODS AND MATERIALS: A retrospective chart review was performed on 100 clinic patients who presented for laser tattoo removal. An algorithm was proposed to assign a numerical score to each tattoo across six different categories (skin type, location, color, amount of ink, scarring, and layering). The cumulative score (Kirby-Desai score) is proposed to correlate with the number of treatment sessions required for satisfactory tattoo removal. RESULTS: A correlation coefficient of 0.757 was achieved, with satisfactory tattoo removal in all subjects (N=100, p<0.001). CONCLUSION: We propose the Kirby-Desai scale as a practical tool to assess the number of laser tattoo-removal sessions required, which will translate into a more certain cost calculation for the patient.

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BACKGROUND: Frequencies of 20 MHz may be appropriate to visualize basal cell carcinomas (BCCs) including their tumor thickness and margins. Histologic comparisons to sonographic images are related at all levels of the epidermis and corium. OBJECTIVE: The objective was to evaluate whether high-frequency ultrasound (HFUS) proved to be an inexpensive and noninvasive modality to adequately delineate tumor margins under favorable circumstances. MATERIALS AND METHODS: Fifty superficial and nodular BCCs of various locations were scanned using a 20-MHz ultrasound device. Tumors were delineated, excised with 4-mm surgical margins, and sent for histologic clearance. Morpheaform, recurrent BCCs, BCCs in areas difficult to scan, and BCCs with specific properties were excluded from this study. RESULTS Clinical and ultrasonic measurements correlated well in terms of width, depth, and length (p<.0005). Of 50 BCCs, 45 were clear after margin assessment with HFUS. Five BCCs depicted extension past 4-mm surgical margins and returned with positive margins. CONCLUSION: HFUS delineated tumor margins adequately, and it appeared to depict subclinical extension past 4 mm on less aggressive BCC variants. It could be warranted if clinical or histologic diagnosis is uncertain. The strong association between clinical and ultrasonic measurements initiates more successful forms of therapy, risk-stratifies specific subgroups of patients, and prevents overall morbidity.

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The availability of a collection of microscope glass slides for review is essential in the study and practice of pathology. A common problem facing many pathologists is the lack of a well-organized filing system. We present a novel system that would be easily accessible, informative, protective, and portable.

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BACKGROUND: Crusted Norwegian scabies is a rare hyperkeratotic variant of scabies infestation. We report herein a case of crusted scabies in a woman with underlying Langerhans cell histiocytosis (LCH). OBSERVATIONS: A 49-year-old woman with LCH was hospitalized owing to marked thrombocytopenia. Her hyperkeratotic skin eruption was thought to be secondary to LCH because several years earlier, she had positive biopsy findings and had been diagnosed as having LCH. After a 1-month hospital stay, her laboratory values improved despite worsening of her skin lesions. CONCLUSION: Analysis of skin scrapings confirmed the presence of scabies, and resolution was achieved with a 1-dose ivermectin treatment.

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Systemic retinoids are an important component of the dermatology treatment armamentarium offering unique therapeutic properties, and are widely used to treat a large spectrum of skin disorders. Rational selection of candidates for treatment, knowledge regarding appropriate and optimal use, awareness of common and uncommon potential adverse reactions, and proper use of clinical and laboratory monitoring can result in effective and safe treatment of several severe skin disorders that impact poorly on the overall health and quality of life of affected patients.

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Sodium lauryl sulfate (SLS) has often been chosen as a model for irritant contact dermatitis (ICD) to study the effect of irritants in combination (1-14). Recently 'tandem', or sequential, exposures with SLS have been performed to study the mechanism of skin barrier impairment in ICD (1-6, 15). The assessment of reactions have been documented with visual scoring, transepidermal water loss (TEWL), skin colour reflectance measurements, skin blood flow; among which TEWL has been noted as the most sensitive value (16). The matched control groups were treated with either a single exposure to a single irritant or in tandem with the same irritant repeatedly. Synergistic and additive effects have been reported for various tandem pairs of irritants, however, the mechanism for both remains unclear. The results of tandem irritation studies were evaluated to define and investigate the responses produced and deduce a possible mechanism of action. Clinical ramifications, albeit complex, are discussed.

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