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Pemphigoid gestationis, which is also known as herpes gestationis, is a rare, pregnancy-associated, autoimmune bullous disease. Treatment depends on the severity of the disease for each patient and the safety and use of these drugs during pregnancy and breastfeeding must be taken into consideration to guide their use. We describe the therapeutic response of two cases of pemphigoid gestationis that did not respond to conventional immunosuppressive therapy or adverse effects limited their use. Both patients eventually received treatment with intravenous immunoglobulin therapy, which resulted in clinical remission. This clinical improvement with disappearance of lesions and a reduction in pruritus was paralleled in a decline in Bullous Pemphigoid Disease Activity Index activity scores, which is a validated scoring system to measure the related condition, bullous pemphigoid.

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Sebaceous carcinoma is a rare but serious malignancy that may be difficult to diagnose when poorly differentiated. Other epithelial tumors with clear cell change may mimic sebaceous carcinoma. Few useful or specific immunohistochemical markers for sebaceous differentiation are available. Nuclear staining with factor XIIIa (clone AC-1A1) was recently found to be a highly sensitive marker of sebaceous differentiation. We evaluated nuclear factor XIIIa (AC-1A1) staining in sebaceous neoplasms vs. other cutaneous clear cell tumors. We stained 27 sebaceous proliferations: sebaceous hyperplasia (7), sebaceous adenoma (8), sebaceoma (5), sebaceous carcinoma (7). We also stained 67 tumors with clear cell change: basal cell carcinoma (8), squamous cell carcinoma (8), hidradenoma (7), desmoplastic trichilemmoma (2), trichilemmoma (10), trichilemmal carcinoma (3), clear cell acanthoma (9), atypical fibroxanthoma (1), syringoma (8), trichoepithelioma (1), metastatic renal cell carcinoma (2), and nevi with balloon cell change (8). Nuclear factor XIIIa (AC-1A1) staining was present in 100% of sebaceous proliferations; 96% displayed strong staining. Non-sebaceous clear cell tumors were negative or only weakly positive with factor XIIIa (AC-1A1) in 95.5%; only 4.5% showed strong staining. This suggests that strong nuclear factor XIIIa (AC-1A1) staining is a sensitive and specific marker of sebaceous neoplasms vs. other clear cell tumors.

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BACKGROUND: Sebaceous proliferations are common and may be confused with other cutaneous neoplasms. Few useful or specific immunohistochemical markers for sebaceous differentiation are available. We incidentally observed strong factor XIIIa (Ventana clone AC-1A1 on Ventana Benchmark Ultra stainer) nuclear staining in normal sebaceous glands and hypothesized that this might be a useful marker in sebaceous proliferations. METHODS: Immunohistochemistry for factor XIIIa (AC-1A1) was performed on seven sebaceous hyperplasias, eight sebaceous adenomas, five sebaceomas, seven sebaceous carcinomas. RESULTS: Strong nuclear factor XIIIa (AC-1A1) staining was present in 100% of normal sebaceous glands, 100% of sebaceous hyperplasia, adenoma and carcinoma, and 80% of sebaceoma. Moderately or poorly differentiated squamous cell carcinomas (SCCs) (n = 26) were also stained for factor XIIIa (AC-1A1); two showed focal strong staining (8%), but the remainder showed only weak or negative staining (92%). In contrast, factor XIIIa clones from Abcam, Cambridge, MA, USA (EP3372) and Vector Laboratories, Burlingame, CA, USA (E980.1) were negative in sebocyte nuclei. CONCLUSIONS: We report the novel finding of consistent nuclear factor XIIIa (AC-1A1) staining in normal, hyperplastic and neoplastic sebocytes. Factor XIIIa (AC-1A1) is a highly sensitive marker of sebaceous differentiation. It may have potential clinical utility as a specific marker to distinguish sebaceous carcinoma from poorly differentiated SCC.

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BACKGROUND: Although much data have been documented on the characteristics of medical school applicants for dermatology and pathology residency programs in the United States and select medical and surgical fellowship applicants through the National Residency Matching Program, little is known about the dermatopathology applicant demographics. METHODS: We examined a 5-year pool of dermatopathology fellowship applicants from a single institution (University of Arkansas for Medical Sciences) and compiled background profile data of the applicants to characterize an 'average dermatopathology fellow' applicant. RESULTS: A total of 229 applicants over a 5-year period were included in the assessment. The majority were of pathology background with medical school and residency training based in the southern United States. One-third of the applicants had original research publications, case reports or had given an oral or poster presentation in the field of dermatopathology. CONCLUSIONS: Knowledge regarding the average applicant statistics for a dermatopathology fellowship will allow prospective applicants to evaluate their own applications for strengths and weaknesses. This will also provide institutions information regarding anticipated statistics for a competitive applicant pool.

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A 26-year-old female presented with a 7 mm irritated pink-red papule on the left posterior shoulder. A shave biopsy revealed a dermal proliferation of epithelioid cells arranged in small nests with central lumen-like structures resembling glands set in a densely sclerotic stroma. S100 and Melanoma antigen recognized by T cells 1 (MART-1) immunohistochemical positivity confirmed a dermal melanocytic neoplasm. Pan-cytokeratin and cytokeratin 7 were negative within the nests ruling out an adnexal neoplasm or metastatic adenocarcinoma. A Spitz nevus variant characterized by the presence of focal tubular structures (tubular epithelioid cell nevus) has rarely been described in the literature and is of uncertain biological significance. Similar structures have also been observed in Clark/dysplastic nevi and melanoma. Glandular differentiation is seen in a wide variety of benign and malignant epithelial neoplasms; however, melanocytes are not known to be capable of forming true glands. The exact mechanism and significance of this phenomenon are currently unknown. Certain postulations include central melanocyte apoptosis, autocrine or paracrine factor secretion or retraction artifact caused by tissue fixation. This distinctive finding is important to recognize in order to avoid misdiagnosis as a glandular neoplasm.

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Sorafenib is a multikinase inhibitor FDA-approved for the treatment of advanced renal cell and hepatocellular carcinoma. Dermatologic side effects include hand-foot skin reaction, facial and scalp erythema and desquamation, splinter subungual hemorrhages, alopecia, pruritus, xerosis, keratoacanthomas, and squamous cell carcinomas. We report sudden eruption of melanocytic nevi diffusely in a patient receiving sorafenib.

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OBJECTIVES: Alopecia is the fifth most common dermatologic diagnosis in African-American patients. Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in this group. This study sought to evaluate clinical and histologic findings in patients without clinical alopecia who use chemical and/or thermal straighteners to determine whether follicular damage is evidenced histologically. METHODS: Eight African-American women with no clinical evidence of alopecia or scalp inflammation were included in the study. All participants had engaged in some form of traumatic hair care within the previous month. Participants submitted to clinical photography and 4-mm punch biopsy. Histologic examination was performed and the characteristics of each case recorded. RESULTS: There were no clinical signs of alopecia or inflammation in any patient. Histopathology showed peri-infundibular lymphocytic inflammation in all patients and mild superficial perivascular lymphocytic inflammation in three. Concentric infundibular fibrosis was observed in each hair follicle in all specimens. One sample showed additional focal peri-isthmus fibrosis. There was no evidence of complete follicular dropout, follicular epithelial thinning, or premature desquamation of inner root sheaths. The mean number of hair follicles was 4.88 per 4-mm punch. Hair cycling was consistently within normal ranges. CONCLUSIONS: Biopsy findings characteristic of CCCA suggest that a clinical prelude exists histologically. Further follow-up may provide a longitudinal timeframe for the potential progression, halting, or reversal of disease if hairstyling practices are, respectively, continued or discontinued. Central centrifugal cicatricial alopecia is likely to represent a common pathway of inflammation and scarring that can be instigated by traumatic hairstyling practices in genetically predisposed subjects.

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The most compelling reason and primary goal of treating actinic keratoses is to prevent malignant transformation into invasive squamous cell carcinoma, and although there are well established guidelines outlining treatment modalities and regimens for squamous cell carcinoma, the more commonly encountered precancerous actinic lesions have no such standard. Many options are available with variable success and patient compliance rates. Prevention of these lesions is key, with sun protection being a must in treating aging patients with sun damage as it is never too late to begin protecting the skin.

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Whether the symptoms are mild, moderate, or severe, the optimal treatment plan is the one the patient is most likely to follow.

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Hypopigmented mycosis fungoides (MF) is a relatively uncommon variant of cutaneous lymphoma that is mostly seen in darker skin types. We present a novel and unique clinical presentation in an African-American female patient, consisting of regular hypopigmented annular rings in areas of normal skin and in more typical hypopigmented patches of MF. The lesions appeared diffusely on all extremities, anterior chest and back. Histopathologic examination showed an atypical lymphocytic infiltrate at the dermal-epidermal junction with epidermotropism and few Pautrier's collections. The patient was otherwise healthy and improved with narrowband ultraviolet (UV)-B. This case represents a presentation of a most unusual variant of hypopigmented MF, for which we propose the name 'annular hypopigmented MF'.

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Chronic plaque psoriasis is a systemic disease affecting over 3% of the population, and many patients are unsatisfied with their current treatment regimen. With advances in understanding of the pathophysiology of psoriasis, new therapeutic options are being developed. The newest of these agents, ustekinumab, offers patients rapid results and the convenience of four annual subcutaneous doses, with efficacy and safety profiles comparable with those of other biologics. However, ustekinumab has been on the market in the US for less than 2 years and will require years of extensive use before the full adverse event profile is fully understood. The purpose of this paper is to summarize the treatment options currently available for psoriasis, with an emphasis on ustekinumab in order to give prescribers an overview of the available data and allow them to make educated and informed prescribing decisions.

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IMPORTANCE OF THE FIELD: TNF-alpha inhibitors such as etanercept have been used for psoriasis for years. A fairly well defined efficacy and safety profile has developed. A new biologic agent, ustekinumab, an IL-12 and IL-23 inhibitor, has recently been released in the US for the treatment of moderate-to-severe psoriasis. The purpose of this article is to compare the efficacy and safety profiles of ustekinumab and etanercept. AREAS COVERED IN THIS REVIEW: We examined safety and efficacy data regarding ustekinumab and etanercept from clinical reports, a head-to-head trial, review articles, and databases and registries from the last 20 years. WHAT THE READER WILL GAIN: Evidence is reviewed about the efficacy for the treatment of psoriasis as well as the safety profiles for both agents, ustekinumab and etanercept. TAKE HOME MESSAGE: Both drugs have data to confirm efficacy and safety in patients with moderate-to-severe psoriasis in the short-term. The limited long-term data on the safety profile of ustekinumab requires careful judgment on the clinician's part, weighing well-defined benefits and potential unknown risks.

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BACKGROUND: Acne vulgaris is a common skin disease that affects patients both physically and mentally. PURPOSE: To examine the prevalence of reported depression in acne patients. METHODS: Patient information was obtained from a medical claims database and analyzed using the Total Resource Utilization Benchmarks process. Benchmarks in this study include: age, gender, co-morbid depression, antidepressant utilization, and acne treatment modality. Depression prevalence in acne patients was compared with general population. RESULTS: Depression was two to three times more prevalent in acne patients than in the general population, with a reported 8.8% of acne patients having clinical depression. The majority of cases of depression and antidepressant therapy utilization were observed in acne patients aged 18 and over with the highest percentage in the 36-64 age group. Approximately 65.2% of the acne patient population was female, with twice as many reported to have depression as males (10.6% females vs. 5.3% males). LIMITATIONS: This analysis included only patients that sought treatment for their acne and had also reported having clinical depression. This may underestimate the total prevalence of acne and associated depression. CONCLUSIONS: Acne is a disease that affects people of all ages both physically and psychologically. A correlation exists between clinical depression and acne patients, particularly those older than 36. "There is no single disease which causes more psychic trauma and more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic assessment than does acne vulgaris" (Sulzberger, 1948).

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INTRODUCTION: Spreading pigmented actinic keratosis (SPAK) is a common, but uncommonly reported or appreciated, variant of classic actinic keratosis (AK). It can mimic different pigmented lesions, which may be benign (eg, solar lentigo) or malignant (eg, lentigo maligna). OBJECTIVE: We sought to review current data and identify areas needing further research to establish diagnostic guidelines for SPAK and to increase awareness of this common entity. METHODS: A literature search was performed in both PubMed and MEDLINE databases using the search terms "spreading pigmented actinic keratosis," "pigmented solar keratosis," "pigmented actinic," and "pigmented solar." Each article was retrieved, reviewed, and summarized. RESULTS: SPAK is a rarely reported lesion that can be difficult to distinguish from other benign and malignant pigmented lesions, including seborrheic keratosis, melanoma in situ (lentigo maligna type), and lentigo maligna melanoma. Located mainly on sun-exposed areas and with a size greater than 1.5 cm, the lesion typically spreads laterally. Pathologically, the lesion resembles classic AK with increased basal melanization. The malignancy potential has not yet been elucidated but destructive therapies such as cryotherapy are recommended. LIMITATIONS: Reports not yet published or not included in the comprehensive databases we used may exist that were not analyzed. CONCLUSIONS: SPAK can be associated with adjacent melanoma in situ; therefore, its diagnosis merits increased suspicion for coexisting melanoma.

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BACKGROUND: The role of the patient-physician relationship is a key issue in the management of lifelong, chronic conditions such as psoriasis, with each side bringing different perspectives. OBJECTIVE: To explore areas of congruence and disconnection in the relationship between psoriasis patients and dermatologists, with a focus on communication issues. METHODS: Three discussion group sessions were held in four centers across the United States with dermatologists, patients, and a follow-up of the dermatologists after watching the patient discussion. RESULTS: Patients want more information on psoriasis, fast treatments, clear expectations from the onset of therapy, and recognition of the emotional burden. Dermatologists found that patients do not receive or internalize adequate information and need further explanation of treatment regimens to increase compliance and patient satisfaction. LIMITATIONS: This was a qualitative study assessing the range of responses and was not a quantitative study designed to test specific hypotheses. The study may not be informative about the experiences of people with psoriasis not actively seeing a physician. CONCLUSIONS: Encounters between physicians and psoriasis patients can be enhanced by providing information on what psoriasis is, choosing fast-acting treatments that patients are willing to use, and providing written materials about the disease and treatment plan.

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BACKGROUND: Patient safety issues are the forefront of delivering effective quality healthcare. The fast pace and high volume of dermatology practice presents an opportunity for new research on error prevention and patient safety. OBJECTIVE: To identify areas of concern in patient safety to introduce starting points for new improvement projects in dermatology. METHODS: Aliterature search was performed using the PubMed database with the search terms 'patient safety' and 'quality of care'. The articles were categorized into three topics concerning patient safety research: safety in treatment and procedures received; safety issues related to facility infrastructure; and human resource management. RESULTS: Many issues identified as healthcare shortcomings such as wrong site surgery, patient misidentification, specimen errors, medication errors, communication failure, poor teamwork, healthcare worker management defects, and facility safety design problems were discussed in the literature. Each of these requires exploration with new safety initiatives for resolution. Alimitation included omitting pieces on occupational health and safety that could contribute to overall patient safety. Our search also included only data from one database. CONCLUSIONS: Patient safety is an ever-evolving process requiring continuous attention by practicing physicians including dermatologists, healthcare staff, patients, and research scholars to discover and implement new safety initiatives for overall healthcare improvement.

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BACKGROUND: Recent studies suggest a shortage of dermatologists with an average wait time of 36 days in the United States and 40 days in Ohio for a routine dermatology visit. To date, no previous studies have examined supply and demand of dermatology services in rural versus urban populations. OBJECTIVE: We sought to determine the average wait time for a dermatology appointment for new and established patients in both urban and rural areas. METHODS: The offices of 250 dermatologists in Ohio were contacted by telephone to determine the wait time for the next available appointment for new and established patients with a changing mole. RESULTS: The average wait time for new (4.5 weeks) and established (3.1 weeks) patients was similar to times reported in previous studies. A greater density of all dermatologists and medical (general) dermatologists practice in cities, but wait times were not statistically different in rural versus urban settings. LIMITATIONS: Neither insurance status or use of physician extenders were considered. The findings may not be applicable to areas outside Ohio. CONCLUSION: There is a shortage of medical dermatologists throughout Ohio. Training more medical dermatologists or adding physician extenders to dermatology practices would be expected to decrease the waiting time for dermatology appointments. Providing incentives for dermatologists to practice in underserved rural areas may not be necessary judging by the similarities in wait times between rural and urban settings.

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BACKGROUND: In April 2004, the National Cholesterol Education Program Adult Treatment Panel III Guidelines for management of high cholesterol encouraged even lower levels of low-density lipoprotein (LDL) than previous guidelines for high and very high risk groups. Assessing patients' risk factors to determine LDL goals is the first step to help guide therapy. OBJECTIVE: To determine whether the use of the Mobile Lipid Clinic Personal Digital Assistant (PDA) Calculator during office visits will increase the number of patients achieving their LDL goal compared to using electronic medical records or conventional methods. METHODS: Four family medicine residency programs affiliated with the Northeastern Ohio Network participated with each site using a different method. The PDA site used the Mobile Lipid Clinic Calculator, the second site used electronic health records (EHRs), the control site used usual care methods, and the transition site moved from paper charts to EHRs during the study. In 2006, baseline chart reviews were conducted to randomly enroll 100 patients per site (aged 40-75 years) with LDL levels at least 10% above goal. In 2007, follow-up chart reviews were conducted on the same patients to determine reductions in LDL and the percent of patients that reached their LDL goals. RESULTS: The percentage reaching their LDL goal and option goal were as follows: PDA site 27% and 12%, EHR site 19% and 3%, control site 4% and 1%, transition site 32% and 12%. Cholesterol-lowering medication usage increased significantly from 38% at baseline to 47% at follow-up (χ(2) = 149.5, P <0.0001). CONCLUSIONS: Using a PDA tool can be just as effective as EHRs in getting patients to their LDL goal and is better than some conventional methods, suggesting the benefit of utilizing technology to improve patient care and health outcomes.