Paraneoplastic Granuloma Annulare Associated with Metastatic Lung Cancer.

A 60-year-old Caucasian woman with a 15-year smoking history presented with new, asymptomatic, pink lesions that gradually appeared over a period of 6 weeks. Physical examination revealed erythematous annular and nummular plaques on her upper and lower extremities, chest, and abdomen (Figure 1A and 1B). A shave biopsy from the right thigh revealed focal areas of necrobiotic collagen in the superficial portion of the dermis, surrounded by histiocytes, multinucleated giant cells, and lymphocytes, consistent with granuloma annulare (GA) (Figure 2).1.

Cutaneous Desmoplastic Leiomyosarcoma Development at Smallpox Vaccination Site.

An 81-year-old man presented to the clinic with a 2.1 cm firm, skin-colored subcutaneous tumor on the left upper arm (Figure 1). The lesion arose at the site of a past smallpox vaccination and had been slowly enlarging for approximately 4 years. The differential diagnosis included sympastic leiomyoma, and a variety of desmoplastic spindle cell lesions such as desmoplastic melanoma, cutaneous spindle cell carcinoma, and desmoplastic leiomyosarcoma. Punch biopsy and immunohistochemical staining revealed positive spindle cells for desmin and caldesmon (Figures 2 and 3). Immunostain for p53 was also strongly and uniformly positive. Owing to poor circumscription on histopathology, symplastic leiomyosarcoma was ruled out. Demoplastic melanoma was also excluded due to positive immunoreaction to muscle markers (desmin and caldesmon) and negative S-100 staining. Additionally, cutaneous spinde cell carcinoma was also ruled out due to negative p63 and cytokeratin staining. Ultimately, clinicopathologic correlation favored a diagnosis of desmoplastic leiomyosarcoma. Staged excisions were performed to eradicate the lesion.

Use of Oral Polypodium Leucotomos Extract in Chronic Photoinduced Hypersensitivity Dermatitis.

A 52-year-old man with Fitzpatrick type V skin presented for evaluation of a photodistributed eruption of unknown origin. The patient reported a 20-year history of the dermatitis, with worsening severity during the past 6 years. He had required one hospital admission with intravenous methylprednisolone and two extended courses of oral prednisone (starting dose of 60 mg/d). He complained of pruritus and swelling localized to the sun-exposed areas of the forearms, face, and neck, with notable sparing of photoprotected areas of his skin. He denied new medications, and a systemic review of systems was noncontributory.

Flagellate shiitake mushroom dermatitis.

An 84-year-old woman presented with 5 days of a pruritic skin eruption that formed arciform and linear patterns. She was diagnosed with flagellate shiitake mushroom dermatitis related to shiitake mushroom consumption the day prior symptom onset.

Therapeutic implications of the circadian clock on skin function.

The human circadian clock ensures that biochemical and physiological processes occur at the optimal time of day. In addition to a central pacemaker in the body, recent evidence suggests that peripheral mammalian tissues also possess autonomous circadian oscillators, which are regulated by genes linked to distinct tissue-specific functions. The skin is situated in a position naturally exposed to diurnal environmental changes. The skin's chronobiological functioning influences skin aging, cell repair and development of skin cancers, as well as optimal timing of drug delivery to the skin. An understanding of circadian skin-related functions and the impact of their disruption allow clinicians to improve therapeutic decision-making and maximize the effectiveness of prescribed treatments.

Long-term durability and dose escalation patterns in infliximab therapy for psoriasis.

BACKGROUND: Infliximab often requires dose escalation to maintain response. Studies regarding long-term durability and dose escalation patterns for psoriasis are few. OBJECTIVE: We sought to evaluate dose escalation patterns in psoriatic patients to identify factors of lack of optimal response to infliximab. METHODS: A retrospective cohort study included 93 patients (216.3 patient-years) treated with infliximab for psoriasis. Kaplan-Meier analysis assessed drug durability. RESULTS: A median infliximab dose of 5.42 mg/kg/mo (range: 2.71-10.83) for a mean of 28 months was administered. Two thirds of patients received a dose escalation. Concurrent methotrexate extended duration of therapy (by a mean ± SD of 19.5 ± 8.1 months, P = .034), including time until first dose escalation (by a mean ± SD of 12.0 ± 6.1 months, P = .037), and failure (by a mean ± SD of 20.7 ± 6.7 months, P = .034). Patients who increased the infusion frequency before increasing the dose remained on infliximab 8.4 months longer than those who first increased the dose (P = .045). Four patients experienced adverse events; 2 required discontinuation. LIMITATIONS: Psoriasis Area and Severity Index, infliximab levels, and antibody titers were not measured. CONCLUSIONS: Dose escalation optimizes durability of infliximab. The probability of maintaining response is enhanced by concomitant methotrexate and increasing the infusion frequency before increasing the dose.

Combination use of ustekinumab with other systemic therapies: a retrospective study in a tertiary referral center.

BACKGROUND: Patients with moderate to severe psoriasis may not respond adequately to single systemic agent and may require combination systemic therapy. OBJECTIVE: To evaluate the prevalence, indications, and response to combination systemic therapy with ustekinumab for psoriasis in a tertiary referral center. METHODS: This retrospective study comprised 102 psoriasis patients treated with ustekinumab at a single tertiary care center. Data was collected pertaining to history of psoriasis, past and current therapies including use of concomitant psoriasis agents, response to therapy, and side effects while on ustekinumab. RESULTS: Twenty-two of 102 (22%) patients were identified as receiving combination systemic treatment involving ustekinumab and at least one additional agent. The most common indication for combination therapy was psoriatic arthritis (35%), followed by bridging therapy (26%), inadequate psoriasis control (13%), prevention of non-melanoma skin cancers (17%), and control of palmoplantar disease (9%). Methotrexate was the additional agent in 12 patients, cyclosporine in 7 patients, acitretin in 5 patients, and 1 patient received a second biologic agent, first etanercept and then adalimumab. Overall, the reduction in body surface area (BSA) was 80% for patients on combination therapy. For those patients on combination therapy for psoriatic arthritis, 75% had resolution or stabilization of their symptoms. Only one patient, receiving cyclosporine, discontinued combination therapy due to adverse side effects. CONCLUSION: Combination systemic therapy with ustekinumab can be effective and well tolerated for patients who cannot be adequately treated with ustekinumab alone.

Use of intralesional cryosurgery as an innovative therapy for keloid scars and a review of current treatments.

Keloids are benign growths characterized by excessive collagen formation. The treatment of keloid scars remains a challenging clinical dilemma for both patients and providers. Intralesional cryosurgery has emerged as a safe and effective new treatment by destroying the hypertrophic scar tissue with minimal damage to the skin surface.