Actinic cheilitis: a treatment review.

All other factors being equal, the presence of actinic cheilitis, a pre-invasive malignant lesion of the lips, doubles the risk of squamous cell carcinoma developing in this anatomic area. Various forms of local ablation,immunomodulation and surgical extirpation have been proposed as therapeutic interventions. This paper critically evaluates the available medical literature to highlight the evidence-based strength of each recommended therapy for actinic cheilitis. Vermilionectomy remains the gold standard for efficacy; trichloroacetic acid application is easy and convenient, but the least efficacious overall.

Innovative uses of thalidomide.

Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.

Thermotherapy in dermatologic infections.

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

Disseminated porokeratosis of Mibelli: A case report.

Porokeratosis is a disorder of clonal hyperproliferation of keratinocytes with several different clinical manifestations. Cutaneous lesions vary in their appearance and distribution. All variants share the distinguishing cornoid lamella on histopathological examination. We present an unusual case of disseminated porokeratosis of Mibelli in an immunocompetent patient.

Acquired dermal melanocytosis of the hand at the site of treated psoriasis.

Dermal melanocytosis is a benign phenomenon most commonly noted in people with darkly pigmented skin. Multiple entities with dermal melanocytosis are described, including Mongolian spot, nevus of Ota, nevus of Ito, nevus of Hori, and acquired dermal melanocytosis. We report a case of acquired dermal melanocytosis occurring in a 42-year-old Hispanic man with psoriasis treated with infliximab for 9 months. The patient presented with an isolated pigmented patch on his left dorsal hand. Histopathologic examination of the skin revealed numerous dendritic, heavily pigmented melanocytes in the papillary and upper reticular dermis. We review the literature and discuss the pathogenesis of acquired dermal melanocytosis.

Granuloma faciale: Case report and review.

Granuloma faciale (GF) is a rare benign chronic inflammatory dermatosis usually appearing only on the face. The lesions of GF typically present as single, asymptomatic, erythematous, non-changing nodules or plaques. We present an illustrative case of GF and briefly review available treatment options.

A paradigm for facial skin rejuvenation.

There is a significant desire by patients to reverse the signs of aging caused by photodamage. Numerous procedures for facial skin rejuvenation have been developed in an attempt to minimize the erythema, dyspigmentation, and rhytides associated with photoaging. The initial procedures developed for facial rejuvenation involve skin resurfacing via complete ablation of layers of skin. Of these procedures, ablative laser resurfacing is the most precise technique and is considered the gold standard for facial skin rejuvenation. Although ablative procedures are quite efficacious, they carry significant patient downtime and risks of adverse effects such as scarring and dyspigmentation. Concerns regarding patient morbidity have led to the development of nonablative procedures that target dermal collagen without damaging the epidermis. Of these technologies, intense pulsed light is the most commonly used because it effectively targets both the erythema and dyspigmentation seen in photoaging. Nonablative techniques minimize side effects and patient downtime; however, they do not match the results seen in fully ablative procedures. Fractional laser technologies-first nonablative and more recently ablative-represent the most recent attempt to match the results seen in fully ablative procedures with less patient downtime. Their results are promising but require further study.

A case series of 48 patients treated with thalidomide.

INTRODUCTION: Thalidomide is approved by the Food and Drug Administration (FDA) for erythema nodosum leprosum, but has been used in many other dermatological conditions that are refractory to standard therapy. METHODS: The medical records of 48 patients treated with thalidomide at Baylor College of Medicine (Houston, TX) were retrospectively reviewed to determine the conditions treated with thalidomide, dosing, efficacy, treatment duration, side effects, adverse events, and reason for discontinuing therapy. RESULTS: Forty-eight patients (men = 18, women = 30) with a mean age of 49.6 years (range: 20-79) were included in this study. Patients were treated for prurigo nodularis, discoid lupus erythematosus, tumid lupus erythematosus, subacute cutaneous lupus erythematosus, systemic lupus erythematosus, lichen planus, lichen planopilaris, cutaneous sarcoidosis, and prurigo nodularis. All conditions were refractory to standard therapy. Patients were treated for a mean of 7.5 months (range: 3 days to 70 months). In most of the disorders, a majority of patients experienced clinical improvement. The most common reason for discontinuation of therapy was side effects, the most frequent being peripheral neuropathy. LIMITATIONS: This study was limited by being retrospective in nature. CONCLUSION: Thalidomide effectively treats some dermatologic conditions that are refractory to standard medications. There are inconveniences associated with obtaining the medication and it is expensive. Physicians must be vigilant for possible side effects, especially peripheral neuropathy.

Brooke-Spiegler syndrome: report of a case of multiple cylindromas and trichoepitheliomas.

We report a case of Brooke-Spiegler syndrome, a rare autosomal dominant disorder caused by mutations of the cylindromatosis gene (CYLD) tumor suppressor gene resulting in multiple cylindromas and trichoepitheliomas. Treatment of these patients can involve surgical excision, laser therapy, or topical applications of aspirin derivatives.

National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents.

BACKGROUND: Chronic immunosuppression is a known risk factor for allowing latent tuberculosis (TB) infection to transform into active TB. Immunosuppressive/immunomodulatory therapies, while highly efficacious in the treatment of psoriasis and psoriatic arthritis, may be associated with an increased rate of active TB in patients receiving some of these therapies. OBJECTIVE: Our aim was to arrive at a consensus on screening for latent TB infection in psoriasis patient treated with systemic and biologic agents. METHODS: Reports in the literature were reviewed regarding immunosuppressive therapies and risk of TB. RESULTS: Screening patients for latent TB infection before commencement of treatment is of utmost importance when beginning treatment with the tumor necrosis factor-alpha inhibitors, T-cell blockers, cyclosporine, or methotrexate. The currently recommended method for screening is the tuberculin skin test. It is preferable that positively screened patients be treated with a full course of latent TB infection prophylaxis before immunosuppressive/immunomodulatory therapy is initiated. However, in the opinion of many experts, patients may be started on the immunosuppressive/immunomodulatory therapy after 1 to 2 months, if their clinical condition requires, as long as they are strictly adhering to and tolerating their prophylactic regimen. LIMITATIONS: There are few evidence-based studies on screening for latent TB infection in psoriasis patients treated with systemic and biologic agents. CONCLUSIONS: The biologic TNF-alpha inhibitors are very promising in the treatment of psoriasis. However, because TNF-alpha is also an important cytokine in preventing TB infection and in keeping latent TB infection from becoming active disease, the use of TNF-alpha inhibitors has been associated with an increased risk of developing active TB. A higher incidence of TB has also been reported with other immunosuppressive/immunomodulatory treatments for psoriasis. It is, therefore, of utmost importance to appropriately screen all patients for latent TB infection prior to initiating any immunologic therapy. Delaying immunologic therapy until latent TB infection prophylaxis is completed is preferable. However, if the patient is adhering to his prophylactic regimen and is appropriately tolerating the regimen, therapy may be started after 1 to 2 months if the clinical condition requires.

Shark skin laceration.

We present a case of multiple lacerations occurring from an encounter with a bull shark in which violent contact was made with the animal's rough skin. Conservative treatment of the injury resulted in good clinical outcome without any complications. Such events are only rarely reported in the medical literature.

Abnormal expression of interleukin-23 in mycosis fungoides/Sézary syndrome lesions.

Progression of mycosis fungoides (MF) to Sézary syndrome (SS) is accompanied by a shift from a T(H)1 to a T(H)2 cytokine profile. Interleukin (IL)-23 is a novel cytokine that shares a common p40 subunit with the T(H)1 inducer, IL-12. IL-23 induces a third profile, T(H)IL-17, that is dominant in inflammation and autoimmunity. Although IL-23 induces an eczematous-like skin reaction in mice, and is expressed in T(H)1-mediated skin disorders such as psoriasis, it has not been evaluated in MF/SS. To study the role of IL-23 in MF/SS development, 40 MF/SS lesions of all stages were immunohistochemically analyzed with a novel anti-human IL-23 antibody raised against full-length human IL-23. IL-23 was detected with the catalyzed signal amplification system. The intensity and frequency of IL-23 staining were semi-quantitatively graded in both the dermal infiltrate and the epidermis. Increased expression of IL-23 was observed throughout the epidermal keratinocytes and in dermal lymphocytes compared to normal skin. IL-23 intensity did not differ significantly among the stages of MF/SS; however, in stage IVB patients, we observed lower frequency of IL-23 expression in dermal lymphocytes than in other stage patients [P = 0.13, analysis of variance (ANOVA)]. Interestingly, clusters of atypical lymphocytes, especially the epidermotropic tumor cells, demonstrated weak or absent IL-23 staining in 18 of 40 (45%) lesions. This finding was present in 4 of 5 (80%) of the stage IVB lesions and 7 of 11 (64%) of the lesions from Sézary patients. These findings indicate that abnormal IL-23 expression may play a role in the pathogenesis and progression of MF/SS.

Segmental neurofibromatosis in association with a large congenital nevus and malignant melanoma.

We describe a patient with segmental neurofibromatosis and a large congenital nevus who developed malignant melanoma in the same anatomic distribution. The overlapping presentation suggests a common etiologic link between neurofibromatosis and large congenital nevi and the possibility that neurofibromatosis increases the risk of melanoma with large congenital nevi.

The optimal strategy for stable tibial fixation in revision total knee arthroplasty.

In revision total knee arthroplasty, the optimal strategy for stabilizing the tibial component in the face of proximal defects remains controversial. The stability of a revision tibial prosthesis was measured using a mechanical surrogate of the revision tibia, while varying the defect treatment proximally and the cortical engagement distally. An offset axial load in combination with an axial torque were applied to each specimen to simulate the stance phase of gait. It was found that, in revision total knee arthroplasty, the mechanical stability of tibial fixation is increased by the addition of a canal filling stem, especially in the presence of poor proximal bone. Proximal tibial coverage, even with a custom-fitted tibial component, adds little additional stability to a tibial tray stabilized by intramedullary engagement of a canal-filling stem.