Initial skin cancer screening for solid organ transplant recipients in the United States: Delphi method development of expert consensus guidelines.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Cutaneous gummatous tuberculosis in a kidney transplant patient.

Cutaneous gummatous tuberculosis (TB) is an uncommon subtype of cutaneous TB that can be seen in notably immunocompromised individuals. We report a case of cutaneous gummatous TB in an immunosuppressed kidney transplant patient. A 60-year-old Cambodian woman presented with fever attributed to recurrent pyelonephritis while on immunosuppressive medications 7 months after kidney transplant. She underwent a bilateral native nephrectomy and was found to have peritoneal nodules, which revealed caseating granulomas and acid-fast bacilli (AFB) consistent with kidney and peritoneal TB. Anti-TB therapy was initiated, resulting in symptom resolution. Subsequently, the Tuberculosis Control Program at the Department of Health (Philadelphia, Pennsylvania) discontinued her medications due to severe thrombocytopenia. During this time, she was closely monitored with blood draws. Approximately 10 weeks after treatment initiation, she noted recurrent fever and a painful, dull red, subcutaneous nodule on the right side of the flank. Biopsy showed an inflammatory infiltrate within the deep dermis indicative of suppurative granulomatous dermatitis. Ziehl-Neelsen stain demonstrated rare AFB within the cytoplasm of macrophages. The patient was restarted on anti-TB therapy resulting in the resolution of her fever and skin lesions. This case illustrates a noteworthy example of a rare form of cutaneous gummatous TB, which should be considered and included in the differential for cutaneous lesions in an immunosuppressed patient.

Plexiform fibrohistiocytic tumor on the chest of a 5-year-old child and review of the literature.

Plexiform fibrohistiocytic tumor (PFT) is a rare neoplasm of mesenchymal origin that can be identified by its propensity for children and adolescents combined with a characteristic histologic arrangement of histiocytes and osteoclast-like giant cells whorled within tumor islands. A 5-year-old female presented with a raised, intermittently tender, and slowly enlarging tumor on her chest, which was histologically confirmed to be a PFT. We present this case along with a comprehensive review of PFT cases reported in the literature to describe the demographic, histologic, and rarely metastatic behavior of this entity. It is important to include PFT on the differential diagnosis of an enlarging tumor in the pediatric population.

Risk factors for keratinocyte carcinoma skin cancer in nonwhite individuals: A retrospective analysis.

BACKGROUND: Because most of the US population will consist of nonwhite individuals by the year 2043, it is essential that both physicians and patients are educated about skin cancer in nonwhite persons. OBJECTIVE: To update the epidemiology, investigate specific risk factors, and facilitate earlier diagnosis and intervention of keratinocyte carcinoma in nonwhite individuals. METHODS: Institutional review board-approved retrospective chart review of all nonwhite patients who had received a biopsy-proven diagnosis of skin cancer at Drexel Dermatology during June 2008-June 2015. RESULTS: Squamous cell carcinoma (SCC) was the most commonly diagnosed skin cancer in black and Asian populations, and basal cell carcinoma was the most common skin cancer in Hispanics. Black persons exhibited the majority of their SCC lesions in sun-protected areas, particularly the anogenital area. On average, current smokers received skin cancer diagnoses 12.27 years earlier than former smokers and 9.36 years earlier than nonsmokers. LIMITATIONS: Single-center design and interpractitioner variability of skin examination. CONCLUSION: The importance of lesions in photoprotected areas in nonwhite individuals should not go overlooked. However, emphasis should also be placed on active examination of sun-protected areas in nonwhite persons and recognition of the relationship between human papillomavirus and genital SCC lesions. Smoking cessation should be integrated in dermatologic counseling of all patients. Interventions tailored to each of these ethnic groups are needed.

Moonlighting in residency: a dermatology perspective.

BACKGROUND: Moonlighting refers to the practice of medicine outside one's training institution in exchange for financial compensation. High medical debt-to-income ratios drive residents to seek additional compensation during residency. OBJECTIVE: To gather information to establish the current practices of moonlighting and to better understand the thoughts and experiences of dermatology residency program directors regarding moonlighting. METHODS: All allopathic and osteopathic dermatology residency program directors in the United States and Puerto Rico received a blinded survey between February 1, 2017 and April 1, 2017 through an email link. RESULTS: Response rate was 47.0%. Of the programs that responded, 63.16% allowed moonlighting. In three regions, 100% of programs allowed moonlighting. The geographic area with the lowest percentage of programs permitting moonlighting was New England with 25%. LIMITATIONS: This survey only reflects the field of dermatology and beliefs/policies of program directors. CONCLUSION: This survey highlighted that training programs allowing moonlighting tend to have a more positive outlook on the practice than programs who do not. Results revealed trends that suggest that states in regions with less access to dermatologic care were more inclined to allow moonlighting.

Comparison of Posttransplant Dermatologic Diseases by Race.

Importance: The risk for skin cancer has been well characterized in white organ transplant recipients (OTRs); however, most patients on the waiting list for organ transplant in the United States are nonwhite. Little is known about cutaneous disease and skin cancer risk in this OTR population. Objective: To compare the incidence of cutaneous disease between white and nonwhite OTRs. Design, Setting, and Participants: This retrospective review of medical records included 412 OTRs treated from November 1, 2011, through April 22, 2016, at an academic referral center. Prevalence and characteristics of cutaneous disease were compared in 154 white and 258 nonwhite (ie, Asian, Hispanic, and black) OTRs. Clinical factors of cutaneous disease and other common diagnoses assessed in OTRs included demographic characteristics, frequency and type of cancer, anatomical location, time course, sun exposure, risk awareness, and preventive behavior. Main Outcomes and Measures: Primary diagnosis of malignant or premalignant, infectious, and inflammatory disease. Results: The 412 patients undergoing analysis included 264 men (64.1%) and 148 women (35.9%), with a mean age of 60.1 years (range, 32.1-94.3 years). White OTRs more commonly had malignant disease at their first visit (82 [67.8%]), whereas nonwhite OTRs presented more commonly with infectious (63 [37.5%]) and inflammatory (82 [48.8%]) conditions. Skin cancer was diagnosed in 64 (41.6%) white OTRs and 15 (5.8%) nonwhite OTRs. Most lesions in white (294 of 370 [79.5%]) and Asian (5 of 6 [83.3%]) OTRs occurred in sun-exposed areas. Among black OTRs, 6 of 9 lesions (66.7%) occurred in sun-protected areas, specifically the genitals. Fewer nonwhite than white OTRs reported having regular dermatologic examinations (5 [11.4%] vs 8 [36.4%]) and knowing the signs of skin cancer (11 [25.0%] vs 10 [45.4%]). Conclusions and Relevance: Early treatment of nonwhite OTRs should focus on inflammatory and infectious diseases. Sun protection should continue to be emphasized in white, Asian, and Hispanic OTRs. Black OTRs should be counseled to recognize the signs of genital human papillomavirus infection. Optimal posttransplant dermatologic care may be determined based on the race or ethnicity of the patients, but a baseline full-skin assessment should be performed in all patients. All nonwhite OTRs should be counseled more effectively on the signs of skin cancer, with focused discussion points contingent on skin type and race or ethnicity.

Nonmelanoma Skin Cancer in Nonwhite Organ Transplant Recipients.

Importance: Organ transplant recipients have a higher incidence of skin cancer. This risk is magnified over time and with continued exposure to immunosuppression. Skin cancer in nonwhite patients is associated with greater morbidity and mortality owing to diagnosis at a more advanced stage, which suggests that nonwhite organ transplant recipients are at even higher risk. Objective: To describe demographic and clinical factors and the incidence of skin cancer in nonwhite organ transplant recipients. Design, Setting, and Participants: We performed a retrospective medical record review of patients who were organ transplant recipients (154 were white and 259 nonwhite [black, Asian, Hispanic, Pacific Islander]) seen from November 1, 2011, to April 18, 2016 at an academic referral center. Main Outcomes and Measures: Variables were analyzed and compared between racial groups, including sex, age, race/ethnicity, Fitzpatrick type, type and location of skin cancer, type of organ transplanted, time to diagnosis of skin cancer after transplantation, and history of condyloma acuminata and/or verruca vulgaris. Results: Most of the 413 patients (62.7%) evaluated were nonwhite organ transplant recipients; 264 were men, and 149 were women. Their mean (SD) age was 60.09 (13.59) years. Nineteen skin cancers were identified in 15 patients (5.8%) representing 3 racial/ethnic groups: black (6 patients), Asian (5), and Hispanic (4). All squamous cell carcinomas in blacks were diagnosed in the in situ stage, located on sun-protected sites, and occurred in patients whose lesions tested positive for human papilloma virus (HPV) and/or who endorsed a history of condyloma acuminata or verruca vulgaris. Most skin cancers in Asians were located on sun-exposed areas and occurred in individuals who emigrated from equatorial locations. Conclusions and Relevance: Nonwhite organ transplant recipients are at risk for developing skin cancer posttransplantation. Follow-up in a specialized transplant dermatology center and baseline total-body skin examination should be part of posttransplantation care in all organ transplant recipients, including nonwhite patients. A thorough inspection of the groin and genitalia is imperative in black organ transplant recipients. History of HPV infection, particularly in black organ transplant recipients, and sun exposure/emigration history in Asian organ transplant recipients should be documented. Vigilant photoprotection may be of lesser importance in the prevention of skin cancer in black organ transplant recipients. Risk factors for nonwhite organ transplant recipients differ between races/ethnicities and warrant further study in efforts to better counsel and prevent skin cancer in these patients.

Vismodegib for locally advanced basal cell carcinoma in a heart transplant patient.

IMPORTANCE: Immunosuppressed patients with solid organ transplants have an increased risk for nonmelanoma skin cancer. Vismodegib has been reported to be effective for select locally advanced or metastatic basal cell carcinomas. However, there is no data documenting the use and safety of vismodegib in immunosuppressed organ transplant patients. OBSERVATIONS: We describe a 78-year-old white man with a history of orthotopic heart transplant, immunosuppressed with low-dose cyclosporine, who presented to a specialty dermatology transplant clinic with multiple, recurrent, locally aggressive facial basal cell carcinomas. Through a multidisciplinary approach, the patient was started on vismodegib therapy. The pharmacokinetics of cyclosporine in the setting of vismodegib administration and weekly monitoring of cyclosporine levels ensured that therapeutic immunosuppression levels were achieved without toxic effects. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first report that details vismodegib use in an immunosuppressed heart transplant patient receiving cyclosporine therapy. With a growing immunosuppressed organ transplant population at high risk for basal cell carcinoma, therapeutic options for locally advanced or metastatic disease are limited. Vismodegib appears to be a safe option for patients receiving cyclosporine therapy with routine monitoring. Future research is needed to evaluate the safety profile of vismodegib with other immunosuppressive agents.

Perioral lesions and dermatoses.

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.

The oldest new finding in atopic dermatitis: subclinical miliaria as an origin.

IMPORTANCE: In 1947, Sulzberger and colleagues published a micrograph of a blocked acrosyringium in a patient with atopic dermatitis (AD), believing that it had a large role in the disease process. Lacking appropriate probes, they could not confirm the finding. OBJECTIVE: To confirm the observations by Sulzberger et al on the blockage of sweat ducts in AD in pathologic specimens. DESIGN AND SETTING: Biopsy specimens diagnostic of various inflammatory diseases and with a secondary differential diagnosis of eczema were evaluated at an academic medical center. EXPOSURES: Evidence of ductal obstruction in each specimen was examined following staining with hematoxylin-eosin, periodic acid-Schiff, and Gram stain. MAIN OUTCOMES AND MEASURES: Comparison of biopsy specimens with control specimens and additional controls consisting of noninflamed skin. RESULTS: Using 36 biopsy specimens, this study confirmed the observations by Sulzberger et al on the blockage of sweat ducts in AD. Blocked acrosyringia were noted in each specimen on routine staining with hematoxylin-eosin. The study also confirmed the findings by earlier investigators about the blockage of sweat ducts in miliaria, showing eosinophilic material in the ducts that was positive for periodic acid-Schiff. Previous researchers also observed bacteria in the blockages, and this study demonstrated the same findings in AD, rather than miliaria. CONCLUSION AND RELEVANCE: Subclinical miliaria may be the earliest change in AD and likely initiates the process that causes intense pruritus.

An unusual variant of confluent and reticulated papillomatosis masquerading as tinea versicolor.

BACKGROUND: Confluent and reticulated papillomatosis (CARP), also known as Gougerot-Carteaud syndrome, is a rare disorder. It usually presents as hyperkeratotic brown papules that coalesce into plaques with a reticulated periphery on the central trunk of young adults. Confluent and reticulated papillomatosis is most often clinically confused with tinea versicolor and usually does not respond to therapy with antifungals. Minocycline is the treatment of choice. OBSERVATIONS: Four cases of CARP with the unusual presentation of hypopigmented lesions masquerading as tinea versicolor in dark-skinned (Fitzpatrick skin types IV-V) patients are presented. All cases exhibited characteristic features of CARP on biopsy results and responded to minocycline of several months' duration. Two of the cases were also treated with adjuvant topical tazarotene. CONCLUSIONS: The hypopigmented variant of CARP in dark-skinned patients makes the clinical differentiation from tinea versicolor extremely challenging. Physicians encountering darkly pigmented individuals with hypopigmented plaques unresponsive to antifungals should have a high clinical suspicion for the hypopigmented variant of CARP.

Cutaneous and systemic plasmacytosis vs. cutaneous plasmacytic castleman disease: review and speculations about pathogenesis.

Cutaneous and systemic plasmacytosis (C/SP), human herpes virus-8 (HHV8), negative multicentric plasmacytic Castleman disease (MPCD), and idiopathic plasmacytic lymphadenopathy are polyclonal plasma cell proliferations of unknown etiology that predominantly affect Asian individuals. Herein, we present our experience with a Vietnamese man with typical C/SP limited to the skin but, after 10 years, may have developed perirenal involvement, and with a white man with human immunodeficiency virus and HHV8 negative MPCD with involvement of skin, lymph nodes, and kidneys at presentation, and who later succumbed to gastric carcinoma. Based on a review of the literature, we suggest that C/SP, cutaneous MPCD, and idiopathic plasmacytic lymphadenopathy with skin involvement are part of a continuum rather than distinct entities and, as such, may be regarded as variants of HHV8-negative MPCD. Although the majority of patients with C/SP run a chronic benign course, special attention should be given to monitoring for pulmonary and renal involvement. We hypothesize that long-lived plasma cells originate and survive in the environment of the skin akin to other stromal "survival" niches due to the local production of interleukin 6 and that such patients might respond to agents that interfere with interleukin-6 activity.

Palisaded neutrophilic and granulomatous dermatitis in association with sarcoidosis.

Palisaded and neutrophilic granulomatous dermatitis (PNGD) has been associated with many conditions including rheumatoid arthritis, systemic lupus erythematosus, systemic vasculitis, and other diseases with circulating immune complexes. Lymphoproliferative conditions, bacterial endocarditis, and various drugs can also induce this condition. Many patients also have symmetric polyarthritis with various serological abnormalities. We present a case of a 46-year-old female who presented with painful erythematous annular plaques and nodules on her legs. The lesions started a week prior to visit and increased in number over the course of the week. The patient had an established history of sarcoidosis with past episodes of uveitis and erythema nodosum. The histopathological findings included a diffuse pandermal infiltrate mostly composed of neutrophils, nuclear debris, and strands of deeply eosinophilic degenerated collagen. Vasculitis was not present. No significant increase in dermal mucin was detected. Based on the clinical and pathological findings, the patient was diagnosed with late-stage PNGD. To our knowledge, this is the first case of PNGD described in an adult patient of sarcoidosis.

Human papillomavirus-associated squamous cell carcinoma of the nail bed in African-American patients.

BACKGROUND: Human papillomavirus (HPV) has been implicated in the development of digital squamous cell carcinoma (SCC). Case reports in the literature mostly identify HPV type 16 present in tumors, but HPV types 2, 31, 34, 35, and 73 have also been isolated. METHODS: Two cases of digital SCC associated with HPV 16 in young African-American men are presented. RESULTS AND CONCLUSIONS: Digital SCC associated with HPV may be difficult to evaluate and treat, particularly in African-Americans and patients with human immunodeficiency virus (HIV). We discuss the need for careful evaluation, treatment, and follow-up of these individuals.

Actinic lichen nitidus.

Actinic lichen nitidus is a unique photoinduced lichenoid eruption that displays histologic features of classic lichen nitidus, with some clinical similarity. It is seen most commonly in deeply pigmented patients (Fitzpatrick skin types V and VI), in photodistributed areas, and during the summer months. Sun avoidance and topical corticosteroids are the mainstay of therapy; however, seasonal recurrences are common. Actinic lichen nitidus has unique properties that differentiate it from classic lichen nitidus. Confusion exists in the literature regarding the nomenclature of this entity, and it appears to be an underrecognized disease in the United States.