Facial psoriasis in the etiology of prolonged erythema following medium-depth chemical peels for severe photodamage.

BACKGROUND: Chemical peeling is the controlled wounding of the epidermis and dermis for skin rejuvenation, involving the application of ablative agents to induce keratolysis and regeneration of damaged cell layers. Prolonged erythema is one complication of this procedure. We report the prevalence and probable etiology of prolonged facial erythema in a cohort of patients treated with medium-depth chemical peels. MATERIALS AND METHODS: A retrospective audit was conducted of all medium-depth facial chemical peels performed at two major teaching hospitals. All patients had severe facial photodamage affecting at least 75% surface area of the face. The occurrence of prolonged erythema following this peel was then identified and analyzed. RESULTS: Of our treatment cohort (n = 82, 51 women, 31 men) with 60 years mean (61.3 years for women, 56.7 years for men), 10 patients (12%; eight women, two men) experienced prolonged erythema beyond a month of treatment. Facial psoriasis was not apparent at the time of chemical peel but manifested as prolonged erythema beyond the expected timeframe following the procedure. CONCLUSION: When patients experience prolonged erythema beyond a month of treatment and fail to respond to standard treatments, clinicians should examine carefully for extra-facial psoriasis prior to this procedure, and also consider facial psoriasis a possible cause of prolonged post-peel erythema.

Recalcitrant Ulcerative Pyoderma Gangrenosum of the Leg Responsive to Tildrakizumab: A Case Report.

Elevated levels of inflammatory mediators-including the interleukin IL-23-are implicated in the pathogenesis of pyoderma gangrenosum (PG), an autoinflammatory neutrophilic dermatosis characterized by rapidly enlarging, suppurative ulcers and cribriform scarring. Here, we present the first case report of significant response of isolated ulcerative PG with tildrakizumab, a biologic agent directed against the p19 subunit of IL-23, in an elderly woman with extensive treatment-refractory PG on her left leg. Tildrakizumab (100 mg subcutaneously at weeks 0 and 4, then every 8 weeks, and eventually increased in frequency to every 6 weeks), combined with acetic acid soaks each morning and chemical debridement every evening with 3% hydrogen peroxide, resulted in progressive decrease in ulcer size and depth, re-epithelialization, and recovery of sensory perception. This report describes the dramatic clinical response of ulcerative PG on the leg with tildrakizumab.

A Case of Male Genital Psoriasis without Involvement of the Glans Penis.

Genital psoriasis is a debilitating condition affecting approximately 49% of male psoriasis patients at least once during their lifetime. This condition often presents as generalized plaque psoriasis and features well-demarcated, erythematous plaques affecting the glans penis and corona. Presentations of male genital psoriasis which disagree with this description may be under- or misdiagnosed, delaying appropriate management. We present the first reported case of chronic plaque psoriasis affecting the penile shaft without involvement of the glans. Both consistent histologic and non-cutaneous features of psoriasis facilitated diagnosis in this patient. The sclerotic plaque on the patient's penile shaft resolved following biologic therapy for psoriasis. This rare presentation of genital psoriasis highlights important learning points for clinicians and dermatopathologists. First, genital psoriasis may affect the penile shaft without involvement of the glans penis. Second, non-cutaneous signs of psoriasis can inform diagnosis when clinical presentation is atypical. Third, psoriasis exhibits a broad spectrum of histopathology.

Clinical clearance of complex basal cell carcinoma in patients receiving sonidegib: A case series.

Basal cell carcinoma (BCC) is the most common cancer worldwide. While most BCC cases respond to surgical management, complex BCC often presents treatment challenges for patients unsuitable for, or refractory to, surgery and radiotherapy-limiting treatment options. Hedgehog pathway inhibitors (HHI) have emerged as an important treatment option for patients with complex BCC-providing a durable treatment modality and improved clinical outcomes. We present a case series of 10 patients with complex BCC treated with sonidegib, an oral HHI, at a dose of 200 mg once daily for a mean duration of 6 months and a mean follow-up of 7 months. Of these patients, sonidegib monotherapy was curative in eight cases. Of the remaining two patients, treatment with sonidegib arrested tumor progression and decreased tumor size to a point where surgical removal was straightforward. The positive treatment response we observed supports use of sonidegib as an effective treatment option for patients with complex BCC.

The Role of Actin in Muscle Spasms in a Case Series of Patients with Advanced Basal Cell Carcinoma Treated with a Hedgehog Pathway Inhibitor.

Basal cell carcinoma (BCC) is the most common cancer globally, with the incidence increasing worldwide by approximately 1% annually. While most cases of BCC can be treated surgically, advanced BCC often poses treatment challenges for patients unsuitable for, or refractory to, radiotherapy and surgery. Since the majority of cases of BCC demonstrate Hedgehog signaling hyperactivation, Hedgehog pathway inhibitors provide durable treatment options and improved clinical outcomes for patients with advanced BCC. One of the most common adverse events seen in patients taking Hedgehog inhibitors includes muscle spasms, which are hypothesized to occur because of calcium influx into the muscle cells. Here we present a case series of patients with muscle spasms during treatment with sonidegib and propose an alternate etiology related to increased actin expression.

Researchers' views on, and experiences with, the requirement to obtain informed consent in research involving human participants: a qualitative study.

BACKGROUND: Informed consent is often cited as the "cornerstone" of research ethics. Its intent is that participants enter research voluntarily, with an understanding of what their participation entails. Despite agreement on the necessity to obtain informed consent in research, opinions vary on the threshold of disclosure necessary and the best method to obtain consent. We aimed to investigate Australian researchers' views on, and their experiences with, obtaining informed consent. METHODS: Semi-structured interviews were conducted with 23 researchers from NSW institutions, working in various fields of research. Interviews were analysed and coded to identify themes. RESULTS: Researchers reported that consent involved information disclosure, understanding and a voluntary decision. They emphasised the variability of consent interactions, which were dependent on potential participants' abilities and interests, study complexity and context. All researchers reported providing written information to potential participants, yet questioned the readability and utility of this information. The majority reported using signed consent forms to 'operationalise' consent and reported little awareness of, and lack of support in implementing more dynamic informed consent procedures, such as verbal informed consent, that was fit for the purposes of their studies. Views on Human Research Ethics Committees (HRECs) varied. Some reported inconsistent, arduous inputs on the information form and consent process. Others expressed reliance on HRECs for guidance, viewing them as institutional safeguards. CONCLUSIONS: This study highlights the importance of transparent relationships, both between researchers and participants, and between researchers and HRECs. Where the relationship with study participants was reported as more robust, researchers felt that they were better able to ensure participants made better, more informed decisions. Where the relationship with HRECs was reported as more robust, researchers were more likely to view them as institutional safeguards, rather than as bureaucratic hindrances. Conscientious and mindful researchers are paramount to ensuring the procedure accommodates individual requirements. This study advocates that when designing ethical informed consent practices, researchers should be integrated as autonomous players with a positive input on the process, rather than, in the worst case, predatory recruiters to be curtailed by information forms and oversight.

High-risk squamous cell carcinoma masquerading as dense inflammation on Mohs frozen sections.

High-risk squamous cell carcinoma (SCC) can present a unique challenge in Mohs surgery. This case report describes how high-risk SCC may masquerade as only a dense inflammation on frozen sections. This feature should raise the index of suspicion for hidden SCC and be a routine indication for further processing by paraffin sections and immunohistochemistry.

Staphylococcus epidermidis: a possible role in the pustules of rosacea.

BACKGROUND: Rosacea is a common skin and ocular disease. Cutaneous rosacea is characterized by facial flushing, telangiectasia, papules, and pustules. It is generally regarded as inflammatory in nature. We believed that the role of bacteria as a contributory factor in pustular and ocular rosacea needed to be revisited. OBJECTIVES: We sought to ascertain whether there is an increase in the bacteria isolated from the (1) pustules of rosacea; and (2) eyelid margins of persons with cutaneous pustular rosacea. METHODS: Bacterial swabs were taken and cultured from an incised rosacea pustule, the ipsilateral cheek skin, and the eyelid margin of 15 patients with pustular rosacea. Swabs were also taken from the cheek skin and ipsilateral eyelid margin of 15 matched control subjects. RESULTS: A pure growth of Staphylococcus epidermidis was isolated from a pustule of 9 of 15 patients with pustular rosacea, and no pure growth of S epidermidis was isolated from their ipsilateral cheek skin. This was a highly statistically significant increase (P = .0003). A pure growth of S epidermidis was isolated from the eyelid margins of 4 of 15 patients with pustular rosacea, and no pure growth was isolated from the eyelids of age- and sex-matched control subjects. This was a statistically significant increase (P = .05). LIMITATIONS: This study focuses on the microbial basis of rosacea. CONCLUSION: Our findings suggest S epidermidis may play a role in pustular and ocular rosacea.

Halo congenital naevus in a middle-aged patient with vitiligo.

A case of halo congenital naevus is reported on the chest of a 56-year-old Asian woman with pre-existing vitiligo. The naevus measured 3.5 cm x 2 cm and underwent depigmentation around its periphery. Dermoscopic examination showed coarse pigment in the darker centre of the naevus and depigmentation in the surrounding halo. Light microscopy showed well-formed naevus cell nests with coarse melanin granules in the papillary dermis, and surrounding fibrosis. Melanocytes extended into reticular dermis, consistent with a congenital growth pattern. There was no evidence of malignancy. The epidermis was of normal appearance. S100 staining highlighted melanocytes in the dermis. Basal melanocytes were retained at the periphery of the naevus. Based on the clinical history and histological findings, a diagnosis of halo congenital naevus was made. The naevus was not excised.

Plaque-like dermatofibroma: A distinct and rare benign neoplasm?

Unusual large dermatofibromata are reported in a 40-year-old man and a 48-year-old man, who both presented with plaques on a lower limb. The largest plaque in each case was well-defined, reddish brown, indurated and measured 50 mm x 30 mm and 70 mm x 40 mm, respectively. Several satellite lesions were present around the large plaques. Dermoscopic examination showed diffuse homogenous pigmentation in the absence of other diagnostic criteria for dermatofibroma. Light microscopy of biopsies from each patient displayed similar features. There was a dermal proliferation of fibrohistiocytic cells that entrapped intervening thickened collagen fibres. The overlying epidermis was acanthotic, and in some instances this showed basal hyperpigmentation. There was no evidence of malignancy. Immunohistochemical staining was positive for Factor XIIIa and negative for CD34. Based on the histological findings, a diagnosis of dermatofibroma was made for each of these cases. Fewer than 20 adult cases of large dermatofibroma of this scale, designated giant dermatofibroma, have been reported to date; and only two have shown a plaque-like appearance, the remainder being pedunculated. The authors propose plaque-like dermatofibroma as a variety of large dermatofibroma distinct to pedunculated giant dermatofibroma.

Efficacy of type-5 phosphodiesterase inhibitors in the drug treatment of premature ejaculation: a systematic review.

This review examines the role of nitric oxide (NO) as a neurotransmitter involved in the central and peripheral control of ejaculation, the methods of phosphodiesterase type 5 inhibitor (PDE5I) drug treatment studies for premature ejaculation (PE), the adherence of methods to the contemporary consensus of ideal PE drug trial design, the impact of methods on treatment outcomes and the role of PDE5Is in the treatment of PE. NO/cGMP transduction is involved in both the central and peripheral control of emission, but evidence for a direct central or peripheral effect of PDE5Is on ejaculation is speculative. Thirteen of the 14 studies reviewed failed to fulfil the evidence-based medicine criteria for ideal PE drug trial design. Limitations of the studies include inadequately defined study populations, the lack of a double-blind placebo-controlled study design, and the absence of consistent objective physiological measures or sensitive, validated outcome assessment instruments as study endpoints. The broad range of intravaginal ejaculatory latency time (IELT) fold-increases reported with PDE5Is, on-demand selective serotonin re-uptake inhibitor (SSRI) drugs, and combined PDE5I/on-demand SSRIs is testament to the unreliability of data and conclusions from methodologically flawed studies. The one study that fulfilled the evidence-based medicine criteria of an ideal clinical trial design reported that treatment with sildenafil failed to significantly increase baseline IELT, supporting our conclusion that there is no convincing evidence to support any role for PDE5Is in the treatment of men with lifelong PE and normal erectile function. However, there is limited evidence to support a potential role for PDE5Is alone or combined with daily or on-demand SSRIs in the treatment of acquired PE in men with comorbid erectile dysfunction. Further controlled studies adhering to the contemporary consensus of ideal clinical trial design are required to clarify the role of PDE5Is in this subgroup of men with acquired PE.

Erythema induratum - a hypersensitivity reaction to Mycobacterium tuberculosis.

Erythema induratum (also known as Bazin disease, tuberculosum, tuberculosis cutis indurativa and nodose tuberculid) is a rare condition that produces painful, firm, and sometimes ulcerated nodules on the lower legs. Distinctive and diagnostic histopathology comprises a septolobular panniculitis, necrosis, granulomatous inflammation and vasculitis.

New agents in the treatment of premature ejaculation.

Premature ejaculation (PE) is a common male sexual disorder. Recent normative data suggest that men with an intravaginal ejaculatory latency time (IELT) of less than 1 minute have "definite" PE, while men with IELTs between 1 and 1.5 minutes have "probable" PE. Although there is insufficient empirical evidence to identify the etiology of PE, there is limited correlational evidence to suggest that men with PE have high levels of sexual anxiety and inherited altered sensitivity of central 5-HT (serotonin) receptors. Pharmacological modulation of the ejaculatory threshold using off-label daily or on-demand selective serotonin re-uptake inhibitors (SSRIs) offers patients a high likelihood of achieving improved ejaculatory control within a few days of initiating treatment, consequential improvements in sexual desire and other sexual domains and is well tolerated. Investigational drugs such as the ejaculo-selective serotonin transport inhibitors (ESSTIs) such as dapoxetine and UK-390,957 represent a major development in sexual medicine. These drugs offer patients the convenience of on-demand dosing, significant improvements in IELT, ejaculatory control, and sexual satisfaction with minimal adverse effects.