Atypical histopathologic features in a melanocytic nevus after cryotherapy and pregnancy.

Melanocytic nevi can undergo clinical and histopathologic changes during pregnancy, as well as after various forms of surgical and nonsurgical trauma. We report the case of a 9-month postpartum 29-year-old female who presented to her dermatologist with a clinically worrisome nevus. This nevus had been treated with liquid nitrogen by her primary care physician 6 months prior to presentation. Histopathologic evaluation revealed a crowded proliferation of atypical melanocytes at the dermal-epidermal junction overlying a scar. The dermal component contained scattered mitotic figures. A combined MART-1, tyrosinase and Ki-67 immunohistochemical study showed foci of increased melanocytic proliferation. These atypical features were interpreted as associated with both the prior cryotherapy, as well as her recent pregnancy. Knowledge of the clinical context in evaluating difficult melanocytic lesions is essential.

Follicular mucinosis and mycosis-fungoides-like drug eruption due to leuprolide acetate: a case report and review.

Leuprolide acetate represents a gonadotropin-releasing hormone agonist, used as part of the treatment of prostate cancer. We report an unusual case of disseminated urticarial rash following leuprolide injection in a 67-year-old man that histopathologically and immunohistochemically resembled mycosis-fungoides, including the presence of follicular mucinosis and eosinophils in the follicles. This histopathologic pattern has not been previously described as a drug reaction pattern due to leuprolide, and it underscores the importance of correlation with the clinical impression to arrive at a correct diagnosis.

Severe cutaneous adverse drug reaction due to fluconazole.

Fluconazole is a rare cause of severe cutaneous adverse drug reactions. A case of a diffuse, exfoliative eruption due to fluconazole is presented. Convincing arguments for a diagnosis of both widespread bullous fixed drug eruption and toxic epidermal necrolysis are made. The clinical presentation, diagnosis, and differentiation of these 2 severe cutaneous acute drug reactions are discussed.

Double-blind study comparing 2 dosages of valacyclovir hydrochloride for the treatment of uncomplicated herpes zoster in immunocompromised patients 18 years of age and older.

A dosage of 1 g of valacyclovir 3 times per day (TID) for 7 days has already been shown to be superior to an oral dosage of 800 mg acyclovir 5 times per day for 7 days in immunocompetent individuals. The objective of this study was to assess the safety and efficacy of an oral dosage of valacyclovir, 1 g TID versus 2 g TID, for the treatment of herpes zoster in immunocompromised patients > or =18 years of age. The oral dosage schedule of 2 g of valacyclovir TID reaches acyclovir plasma levels similar to those achieved with intravenous acyclovir therapy given to immunocompromised patients (10 mg/kg every 8 h for 7 days). In this double-blind study, 87 immunocompromised patients with clinical evidence of localized herpes zoster were randomized to receive oral valacyclovir therapy for 7 days, either 1 g TID or 2 g TID, within 72 h after onset of zoster rash. Patients were seen and assessed for cutaneous healing, zoster-associated pain (ZAP), and/or zoster-associated abnormal sensations (ZAAS), up to 24 weeks. Participants in both arms of the study demonstrated similar median times to full crusting of the rash (8 days), and both dosages were safe and effective therapies for reduction of ZAP and ZAAS in the immunocompromised patient population.

Managing herpes zoster in immunocompromised patients.

Herpes zoster infections are more common and often more complicated in immunocompromised patients. The key clinical objective in these patients is to reduce the incidence of cutaneous and visceral dissemination that can lead to life-threatening complications. This is best achieved with prompt antiviral therapy, which should be instituted in all immunosuppressed zoster patients if presentation occurs within 1 week of rash onset or any time before full crusting of lesions. For localized disease, most patients can be treated with oral valaciclovir, famciclovir or aciclovir, with close outpatient follow-up. Intravenous aciclovir therapy is reserved for those with disseminated varicella zoster virus infection, ophthalmic involvement, very severe immunosuppression or the inability to take oral medications. Foscarnet is the drug of choice to treat aciclovir-resistant herpes zoster. Appropriate analgesic therapy should be combined with early antiviral treatment to reduce the incidence and severity of acute zoster pain and post-herpetic neuralgia.

Valacyclovir for the treatment of genital herpes.

Genital herpes is the most prevalent sexually transmitted infection in the USA. While sometimes mild in severity, it can be a distressing and painful chronic condition. Likewise, herpes labialis and herpes zoster can be both physically and psychologically painful. While there is no cure for these conditions, treatment to alleviate symptoms, suppress recurrences and reduce transmission has been drastically improved over the past 20 years with the use of guanine nucleoside antivirals, such as valacyclovir hydrochloride (Valtrex), GlaxoSmithKline) the highly bioavailable prodrug of acyclovir (Zovirax((R)), GlaxoSmithKline), and famciclovir (Famvir, Novartis), a highly bioavailable prodrug of penciclovir (Denavir, Novartis). Clinical trials involving approximately 10,000 patients (including patients from nongenital herpes studies, such as herpes zoster) have assessed the safety and efficacy of valacyclovir in the treatment of initial genital herpes outbreaks, episodic treatment of recurrent episodes and daily suppressive therapy. It was shown that valacyclovir has similar efficacy to acyclovir in the episodic and suppressive treatment of genital herpes. Valacyclovir is the only antiviral drug approved for a once-daily dose of suppressive therapy for genital herpes, as well as the only antiviral drug US FDA approved for a 3-day regimen of episodic treatment of recurrent genital herpes. In addition, valacyclovir is also indicated in the reduction of the sexual transmission of herpes simplex virus infection and for the treatment of herpes labialis. In herpes zoster, valacyclovir is more effective than acyclovir or placebo (and as equally effective as famciclovir) in shortening the length and severity of herpes zoster-associated pain and postherpetic neuralgia. Valacyclovir has an acceptable safety profile in patients with herpes simplex and herpes zoster. The less frequent dosing regimen makes it an attractive option in the treatment of genital herpes and other viral infections, and may contribute to increased patient adherence to therapy.

Cutaneous Infection with Mycobacterium abscessus in a child.

Nontuberculous mycobacteria can cause cutaneous infections in both children and adults. Localized nontuberculous mycobacterial infections of the skin have been reported in children following injections or surgical procedures. We report a child who developed a cutaneous nontuberculous mycobacterial infection after exposure of a skin wound to pond water. Cutaneous infection with the rapidly growing mycobacteria Mycobacterium abscessus was demonstrated by clinical and histologic evaluation on the lower leg of an otherwise healthy 12-year-old Caucasian boy. We describe this as an instance of an unusual acquisition of cutaneous M. abscessus infection in a child.