Transient Erythema Elevatum Diutinum Associated With HIV Viremia.

Erythema elevatum diutinum (EED) is a rare cutaneous small vessel vasculitis of unknown etiology. It is thought to be due to immune complex deposition in small vessels, resulting in complement fixation and subsequent inflammation. EED classically presents with asymptomatic, symmetric, red-brown to purple papules, plaques, and nodules overlying extensor surfaces with a lapsing-remitting course that typically resolves within five to 10 years. We discuss the case of a 47-year-old male with HIV and a new history of EED presenting after several days of missed antiretroviral medications and resolved with improved compliance with antiretroviral medications. A 47-year-old male presented with a four-week history of mildly tender violaceous plaques and nodules on the dorsal feet and posterior heels bilaterally. Medical history was significant for HIV that was well-controlled on antiretrovirals although the patient had missed two days of therapy. A punch biopsy of the lesion demonstrated leukocytoclastic vasculitis with dense dermal mixed infiltrate consisting of histiocytes, neutrophils, and eosinophils. Laboratory findings revealed the presence of HIV RNA. Prior to the initiation of Dapsone therapy, the patient's eruption cleared entirely within a month solely by restarting his antiretroviral therapy, for which he continues to remain disease-free. EED is a rare, chronic leukocytoclastic vasculitis with a poorly understood etiology. Treatment is typically aimed at treating underlying systemic disease, however, treatment of EED with Dapsone is typically first-line.

Association of Tumor Characteristics With Insurance Type Among Patients Undergoing Mohs Micrographic Surgery for Nonmelanoma Skin Cancer.

Importance: Little is known about the association between insurance type and tumor or treatment characteristics among patients undergoing Mohs micrographic surgery (MMS) for nonmelanoma skin cancer (NMSC). Objective: To investigate whether there are differences in tumor and treatment characteristics among patients undergoing MMS for NMSC by insurance type. Design, Setting, and Participants: This retrospective cohort study included patients with NMSC who presented for surgery at an academic MMS practice between May 2017 and May 2019. Main Outcomes and Measures: Preoperative and postoperative tumor diameters, number of MMS stages, type of closure, and number of high-risk tumors were compared based on insurance type among uninsured and underinsured patients and those with private insurance, Medicare, and Veterans Affairs (VA) insurance. Results: A total of 1397 patients with NMSC (978 [70%] male; mean [SD] age, 68.5 [12.4] years) underwent 1916 MMS procedures. Of these patients, 868 (45%) had Medicare, 570 (30%) had private insurance, 299 (16%) had VA insurance, and 179 (9%) were treated at a safety net clinic or were uninsured. Compared with patients with private insurance, uninsured and underinsured patients had significantly larger preoperative tumor bed diameters (difference, 28%; 95% CI, 14%-43%; P < .001) and postoperative defect sizes (difference, 28%, 95% CI, 16%-41%; P < .001). Patients with Medicare and VA insurance did not have significantly different preoperative tumor bed diameters compared with patients with private insurance. Patients with VA insurance had larger postoperative defect sizes than patients with private insurance (difference, 12%; 95% CI, 2%-23%; P = .02). The number of MMS stages and type of closure did not significantly differ based on insurance type. Conclusions and Relevance: In this cohort study of patients undergoing MMS for NMSC, larger preoperative tumor and postoperative defect sizes were associated with being uninsured or underinsured compared with privately insured. Future studies are required to determine why these differences exist to deliver optimal care to all patients.

Management of a neonate with diffuse cutaneous mastocytosis: Case report and literature review.

Mastocytosis is an accumulation of clonal mast cells within tissues, commonly caused by mutations in the KIT proto-oncogene. This report describes the management of a neonate with diffuse cutaneous mastocytosis (DCM) caused by a rare activating KIT mutation, specifically internal tandem duplication of the Ala502Tyr503 pair on exon 9, and reviews current data regarding work-up of DCM in pediatric patients.

Caring for Pediatric Patients With Epidermolysis Bullosa in the Emergency Department.

Epidermolysis bullosa (EB) refers to a heterogeneous group of genetic disorders characterized by epithelial fragility. We provide guidelines for management of pediatric patients with EB in the emergency department based on a review of literature, as well as insights from our own experiences caring for patients with EB. The purpose of the guidelines proposed is prevention of avoidable iatrogenic trauma to the skin and mucosa of patients with EB who are presenting to the emergency department for a variety of reasons.

Allergy testing in dermatology and beyond.

Allergy is a broad term referring to an acquired alteration of the immune system in reaction to an antigen and can affect every organ system including the skin. Patients, dermatologists, and nondermatologist physicians may use this term in a variety of ways that do not necessarily refer to the same biological process or clinical presentation, which creates difficulty in adequate communication and expectation setting regarding workup and management of allergic conditions. The purpose of this article is to provide a brief background on the pathophysiology of common presentations of allergic disease; discuss routinely used allergy tests and their indications; and provide a more detailed review of patch testing, the most frequently used allergy test in dermatology.

Bedside microscopy for the beginner.

Novice microscopists may struggle with identifying both the appropriate lesion for bedside testing as well as preparation and interpretation of the specimen. This article will serve as a guide to identify what type of primary lesion should prompt consideration of microscopic evaluation in the outpatient setting, provide specific details about how to properly obtain and analyze such a specimen, and elaborate basic information about the interpretation thereof.

Establishing financial literacy: what every resident needs to know.

Financial literacy is a skill that requires an ongoing investment of time and often is overlooked throughout medical training. Physicians are facing an unprecedented student loan burden upon graduation from medical school, coupled with stagnant and decreasing salaries and few financial skills to help navigate this terrain. The purpose of this article is to address several specific steps every resident should take during training to establish good financial practices.

Therapeutic interventions to lessen the psychosocial effect of vitiligo in children: A review.

Vitiligo commonly affects children, with half of affected individuals experiencing disease onset before the age of 20. Because childhood is a time of advancement in social and psychological development, understanding the extent of the effect of the disease and means of alleviation is crucial. Vitiligo has been shown to decrease children's quality of life, with greater distress in children with highly visible lesions and darker skin tones. This article reviews the literature regarding interventions that have been analyzed in children. Studies evaluating the effect of camouflage, cognitive behavioral therapy, psychological self-help tools, and support groups on the psychosocial aspects of vitiligo were included. The review highlights the ongoing need for studies to better understand the modalities described in this article, as well as others, such as skin dyes, bleaching creams, medical tattooing; week-long camps that cater to children with chronic skin disease; and biofeedback, that might have a role in preventing the psychosocial sequelae of childhood vitiligo.

Climate change and skin disease.

Despite commanding essentially universal scientific consensus, climate change remains a divisive and poorly understood topic in the United States. Familiarity with this subject is not just for climate scientists. The impact of climate change on human morbidity and mortality may be considerable; thus, physicians also should be knowledgeable in this realm. Climate change science can seem opaque and inferential, creating fertile ground for political polemics and undoubtedly contributing to confusion among the general public. This puts physicians in a pivotal position to facilitate a practical understanding of climate change in the public sphere by discussing changes in disease patterns and their possible relationship to a changing climate. This article provides a background on climate change for dermatologists and highlights how climate change may impact the management of skin disease across the United States.

Disseminated Syringomas of the Upper Extremities in a Young Woman.

Syringomas are benign, eccrine sweat gland tumors frequently found on the eyelids and neck in post-pubescent women and may present in healthy individuals or be associated with various medical comorbidities. We present a case of an otherwise healthy 19-year-old female with an abrupt onset of disseminated syringomas on the bilateral forearms and dorsal hands. Eruptive acral syringomas have not been previously reported in adolescents, and this diagnosis should be considered in patients presenting with a papular eruption on the hands and forearms.

The membrane type matrix metalloproteinase MMP14 mediates constitutive shedding of MHC class I chain-related molecule A independent of A disintegrin and metalloproteinases.

Engagement of tumor cell surface MHC class I chain-related molecule A (MICA) to NKG2D stimulates NK and T cell antitumor immunity. Shedding of MICA by tumor cells facilitates tumor immune evasion, which may in part contribute to tumor progression. Thus, elucidating the mechanisms by which tumors shed MIC is of great importance for therapy to reinforce NK and T cell antitumor immunity. In this study, we report that the membrane type matrix metalloproteinase (MMP)14 mediates MICA shedding. Suppression of MMP14 expression blocks MICA shedding. Concomitantly, overexpression of MMP14 enhances MICA shedding. The regulation of MICA shedding by MMP14 is independent of the activity of a disintegrin and metalloproteinases, which have been reported to mediate MICA shedding. Finally, MMP14 expression in MICA-positive tumor cells regulates the sensitivity of tumor cells to NK cell killing. These findings suggest that MMP14 may be a new target for tumor immune therapy.

An six-amino acid motif in the alpha3 domain of MICA is the cancer therapeutic target to inhibit shedding.

Expression of the MHC class I chain related molecules A and B (MICA/B) on tumor cell surface can signal the immune receptor NKG2D for tumor immune destruction. However, MIC was found to be shed by tumors in cancer patients, which negatively regulates host immunity and promotes tumor immune evasion and progression. The mechanisms by which tumors shed MIC are not well understood although diverse groups of enzymes are suggested to be involved. The functional complexity of these enzymes makes them unfeasible therapeutic targets for inhibiting MIC shedding. Here we identified an six-amino acid (6-aa) motif in the alpha3 domain of MIC that is critical for the interaction of MIC with ERp5 to enable shedding. Mutations in this motif prevented MIC shedding but did not interfere with NKG2D-mediated recognition of MIC. Our study suggests that the 6-aa motif is a feasible target to inhibit MIC shedding for cancer therapy.

Oxidative DNA damage in the prostate may predispose men to a higher risk of prostate cancer.

DNA damage has been associated with prostate cancer risk. Men who were referred for initial prostate biopsy for elevated prostate-specific antigen or abnormal digital rectal examination are often found with no cancer but have a higher risk of developing prostate cancer than the general population of men in their lifetime. In this study, we investigated whether DNA damage is one of the factors that predispose these men referred for prostate biopsies to a higher risk of prostate cancer. We found significantly elevated levels of 8-oxo-2-deoxyguanosine immunoreactivity in the prostates of the referred men (n = 50) in comparison to the control prostates of men (n = 32) with no indication for referral for prostate biopsy. Twelve of these control men were healthy middle-aged men and 20 of them were older men whose conditions were diagnosed with bladder cancer but with normal serum prostate-specific antigen and digital rectal examination and no evidence of prostate disease. In all the 8-oxo-2-deoxyguanosine-positive prostates, we detected phosphorylation of the ataxia telangiectasia mutated kinase and expression of the immune-stimulatory molecule MIC in the prostate epithelium. These data suggest that: 1) oxidative DNA damage has occurred in the "referred" but pathologically normal prostates, indicating that these prostates may be subjected to genomic instability and eventually neoplastic transformation; 2) in response to DNA damage, two surveillance pathways, represented by ataxia telangiectasia mutated phosphorylation and induction of the NKG2D ligand MIC, were activated to prevent tumorigenesis.