Ulcerative erythematous papules and plaques on the face and lower legs of a man living with HIV: a clinicopathological challenge.

A 44-year-old male presented with a 2-month history of erythematous ulcerative papules and plaques on the scalp, face, and bilateral lower legs. He had a 5-year history of well-controlled HIV on antiretroviral therapy and recurrent syphilis infections. His face had violaceous plaques, while bilateral ankles and calves had ulcerative lesions with necrotic centers and purple borders. The morphologies clinically mimicked pyoderma gangrenosum on the lower extremities and cutaneous lymphoma on the face. Biopsy and reactive rapid plasma reagin confirmed a diagnosis of lues maligna, and the patient was successfully treated with penicillin G benzathine.

Skin cancer risk in people living with HIV: a call for action.

A diagnosis of HIV poses secondary medical risks to patients, ranging from infections to neoplastic conditions. Regarding skin cancer, these risks extend beyond the well known association with Kaposi sarcoma and include Merkel cell carcinoma, squamous cell carcinoma, and high-risk melanomas. Despite evidence of these risks, knowledge and awareness remain low, among care providers for people living with HIV, individual patients, and even some specialists in dermatology. Crucially, medical organisations do not adequately address this concern, as there is an absence of treatment guidelines for the screening and management of skin cancer for people living with HIV. To continue providing high-quality care for this population, the increased risk of multiple high-risk skin cancers needs to be appropriately recognised by both providers and patients. Accordingly, we call for renewed emphasis on patient education and implementation of improved organisational guidelines for skin cancer screening protocols.

Management of Neovaginal Secretions After Salvage Gender Affirming Right-Colon Vaginoplasty Using Glycopyrrolate.

Purpose: We report a novel case of a transgender woman who experienced excess mucosal secretion leading to symptomatic skin irritation after her colonic vaginoplasty successfully treated with glycopyrrolate. Methods: This is a case report of a 47-year-old transgender woman with symptomatic excess mucosal secretion and skin irritation from colonic vaginoplasty, and we describe her treatment course and responses. Patient consent was obtained for publication. Results: The patient's chronic neovaginal discharge improved with glycopyrrolate. Conclusions: Anticholinergic drugs may be helpful in treating patients who experience chronic neovaginal discharge following colonic vaginoplasty.

Biologic Therapies in HIV/AIDS Patients with Inflammatory Diseases: A Systematic Review of the Literature.

Biologic therapies have been increasingly developed and used for the treatment of severe inflammatory diseases. However, the safety and efficacy profile of biologic drugs in patients with HIV is not well established as this patient population is historically excluded from clinical trials. We review the available evidence of biologic use in people with HIV. We conducted a systematic review of the literature up to June 29, 2022 and included studies that treated patients with HIV who have inflammatory disease using biologic drugs. Clinical data regarding safety and efficacy were abstracted into tables. One hundred twelve studies were included, and 179 patients were included in our study. Nearly all classes of biologics drugs had a favorable safety profile with minimal or minor adverse events. Anti-CD-20 inhibitors and TNF-alpha inhibitors were associated with opportunistic infections. Transient increase in HIV viral load was noted with use of some agents such as TNF-alpha inhibitors. The quality of evidence is low, restricted to case reports and retrospective reviews. However, the safety profile of biologics observed in these patients with HIV was overall favorable.

Mpox-A Rapidly Evolving Disease.

The 2022 mpox outbreak has rapidly emerged onto the global medical scene while the world continues to grapple with the COVID-19 pandemic. Unlike COVID-19, however, most patients with mpox present with skin findings, the evolving clinical presentation of which may be mistaken for other common skin diseases, particularly sexually transmitted infections. This Special Communication provides an overview of the evolution of mpox skin findings from its initial description in humans in 1970 to the present-day multinational outbreak.

A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring.

BACKGROUND: In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression. OBJECTIVE: The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time. METHODS: The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals. RESULTS: From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases. LIMITATIONS: Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity. DISCUSSION: These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.

Syphilis: recommendations for dermatologists on a resurgent epidemic.

Despite reaching historical lows in the early 2000s, cases of both primary and secondary syphilis and congenital syphilis have increased dramatically in the U.S. over the last decade. In the U.S., the current syphilis epidemic is disproportionately impacting communities that have been historically underserved in medicine. These include men who have sex with men, especially those infected with HIV; people of color; and reproductive-age women with poor access to prenatal care. With syphilis now being more commonly diagnosed in non-STI than STI clinics in all genders, and since primary and secondary syphilis and congenital syphilis present with characteristic mucocutaneous manifestations, dermatologists are in a position to help reduce the advance of this preventable epidemic, by actively considering this diagnosis and incorporating syphilis screening into their practice. Herein, we delineate strategies by which dermatologists can contribute to this critical effort in their roles as clinicians, public health advocates, and researchers. In particular, we discuss the rapidly changing demographics of syphilis, nuances in serologic testing and treatment, strategies to increase public healthcare access and equity in these underserved populations, and research gaps in this field.

Topical treatments for Kaposi sarcoma: A systematic review.

Background: While treatment options exist for solitary or disseminated Kaposi sarcoma (KS) disease, there are currently no standardized clinical treatment guidelines for cutaneous KS. Objective: This systematic review seeks to identify safe and effective topical treatments for cutaneous KS lesions. Methods: We conducted a systematic review using peer-reviewed articles from January 1970 to September 2021 published in the PubMed/MEDLINE and EMBASE databases. Results: From the initial search that yielded 590 studies, 34 met the inclusion criteria and were selected. Of the 34 studies, seven were clinical trials, 26 were case reports/series and one was a multicentre study. A total of 634 patients were included in our review. The three most common topical treatments used for cutaneous KS were imiquimod, alitretinoin and timolol. Topical alitretinoin was used in three case reports and three clinical trials. Topical imiquimod was used in eight case reports, one prospective phase II cohort study and one comparative single-blinded non-controlled clinical study. Topical timolol was used in nine case reports/series. Our review also identified reports of less widely used topical treatments for cutaneous KS. These include topical diphencyprone (DPCP), all-trans-retinoic-acid, rapamycin and bleomycin-dimethylsulfoxide (BLM-DMSO) which achieved variable response rates but have not been widely studied. Conclusion: Topical alitretinoin, imiquimod and timolol demonstrated positive responses for cutaneous KS and the treatments were well tolerated. These three topical treatment modalities could be considered by clinicians when treating cutaneous KS.

Primary nasal Kaposi Sarcoma in well-controlled HIV-positive patient with normal CD4 count associated with long-term nasal steroid use.

Kaposi sarcoma (KS) is an angioproliferative disease that is caused by human herpesvirus 8. The epidemic form of KS is associated with acquired immunodeficiency syndrome (AIDS) and is common in HIV-positive patients with CD4 counts less than 200 cells/mm. We present the case of a 63-year-old man with well-controlled HIV and normal CD4 count developing atypical nasal KS associated with intranasal steroid use.

Herpes simplex virus-2 associated with a large fungating penile mass.

A 48-year-old male with HIV/AIDS presented with an enlarging nodular lesion on the base of his penis. Histology revealed changes consistent with chronic viral infection and culture grew herpes simplex virus 2 (HSV-2). The lesion was refractory to valacyclovir and intralesional (IL) cidofovir therapy. Urology excised the mass and the defect was repaired primarily with good cosmetic result. Post-operative pathology confirmed HSV-2 despite the unusual appearance of the lesion consisting of nodular mass without gross ulceration.

Cost Minimization Analysis of a Teledermatology Triage System in a Managed Care Setting.

Importance: Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact. Objective: To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California. Design, Setting, and Participants: A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017. Intervention: Implementation of the TD triage system in January 2015. Main Outcomes and Measures: The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model. Results: The analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378. Conclusions and Relevance: Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.

Effect of Topical Brimonidine on Alcohol-Induced Flushing in Asian Individuals: A Randomized Clinical Trial.

Importance: Alcohol flushing syndrome (AFS, also known as Asian glow and Asian flush) affects 20% to 47% of East Asians and causes significant psychosocial distress. There are no approved treatments for this condition. Objective: To determine whether brimonidine gel, 0.33%, decreases facial erythema in patients with AFS after consumption of alcohol. Design, Setting, and Participants: In this randomized clinical trial, 20 healthy volunteers of East Asian descent with a self-reported history of AFS were recruited between April 2018 and March 2019. Interventions: Participants were randomized to application of brimonidine gel to either the left or right half of their face. Placebo control was applied to the opposite side. After 30 minutes, participants ingested alcohol. Main Outcomes and Measures: Outcomes were specified before data collection. The difference in erythema between the treated and placebo side of each participant's face was measured 60 minutes after drug application (primary outcome) and at 90 and 120 minutes after drug application (secondary outcomes). Participants were asked to rate their likelihood of using the medication again and their likelihood of recommending the medication to a friend on a scale of 0 to 10. Results: The mean (SD) age of the 20 individuals enrolled in the study was 30.5 (8.4) years, and there were 10 women (50%). There was a significant difference in erythema at 60 minutes after drug application as measured by the difference in Clinician Erythema Assessment score (2.1; 95% CI, 1.5-2.71; P < .001) and by the difference in Subject Self-Assessment score (1.7; 95% CI, 1.1- 2.3; P < .001). This effect persisted at 90 and 120 minutes. Individuals were likely to use the medication again (7.2; 95% CI, 6.0-8.3) and would also recommend it to a friend (7.6; 95% CI, 6.5-8.6). Conclusions and Relevance: This study demonstrates that brimonidine gel is effective in reducing the facial erythema of AFS. Patients with psychosocial distress due to AFS may benefit from treatment with brimonidine. Trial Registration: ClinicalTrials.gov identifier: NCT03497442.