Sun protection behaviors among people living with HIV.

People living with HIV (PLWH) are at increased risk for both melanoma and nonmelanoma skin cancers, but there is currently no data on sun protection behaviors among PLWH. We created a 28-question paper survey to collect information on patient demographics and sun protection behaviors among PLWH. We found that although 71.6% of respondents reported spending at least 30 minutes to two hours in the sun daily, only 29.7% reported consistent use of sunscreen. In addition, 41.9% rarely or never received sunscreen counseling by their healthcare providers. There is therefore a need for increased training for healthcare providers in sun protection behavior counseling for PLWH.

The Relationship Between Epidermal Mitotic Density, Atypical Mitotic Figure Density, Breslow Depth, Ulceration, and Dermal Mitotic Rate in Cutaneous Melanoma: A Retrospective Cohort Study.

Prognostic factors for melanoma include Breslow depth (BD), ulceration, and dermal mitotic rate (DMR). No studies have queried the effect of epidermal mitotic density (EMD) or atypical mitotic figure density (AMD) in an outcome-based assessment. Our objective was to determine if there is a relationship between EMD, AMD, BD, DMR, and ulceration and patient outcomes. This was a retrospective cohort study of 185 cases of thick and thin melanomas. Univariate and multivariate cause-specific regression analysis was performed. There was a positive correlation between EMD and BD (P = .0001). The difference between AMD in thick and thin melanomas was statistically significant. For every unit increase in EMD, patients had a 2.8-fold increase in the risk of distant metastasis; however, statistical significance was lost in the multivariate analysis. In adjusted analyses, ulceration, DMR, and BD were associated with outcomes. There were no statistically significant correlations between AMD and outcomes. This study is limited by its small sample size, diminution of the epidermis in some thick melanomas preventing EMD estimates, and reproducibility of mitotic figure counting. EMD and AMD do not seem to have any independent value in multivariate analyses for melanoma. Ulceration, BD, and DMR were significantly associated with outcomes and further solidify these known predictors of prognosis.

Local immune cell infiltration in cutaneous acute graft versus host disease.

BACKGROUND: Hematopoietic stem cell transplant is a crucial intervention to definitively treat many hematopoietic malignancies, but it carries great risks of morbidity and mortality often associated with graft-versus-host disease (GVHD). Acute and chronic GVHD are distinct entities, defined by a combination of historical, clinical, and pathologic data, but both are generally thought to stem from self-propagating aberrantly activated immune cells inflicting end organ damage, with the potential to cause significant illness or even death. Event-free survival rates after hematopoietic stem cell transplant continue to improve each year, but GVHD remains a major hurdle in improving the efficacy and safety of transplant. OBJECTIVE: Recent studies demonstrating tissue-specific immune effector phenotypes underscore the need for a deeper understanding of the cellular and molecular pathways driving the destruction of target tissues in patients with acute GVHD. METHODS: Samples were collected from lesional and unaffected skin in five patients with acute cutaneous GHVD. Fresh tissue was processed for fluorescence-activated cell sorting and analysis of macrophages and lymphocytes. RESULTS: The percentage of lymphocytes and macrophages as a representation of total cells varied among patients and was not always consistent between lesional and unaffected sites. The heterogeneity in immune cell profiling observed in patients in this study could reflect the diverse demographics, conditioning, and transplant conditions of each individual. CONCLUSION: This study provides initial insight into the underlying molecular mechanisms of cutaneous GVHD progression and paves the way for additional studies to examine the cellular and molecular landscape in greater detail.

Lichenoid inflammation of DSAP lesions following treatment with durvalumab, olaparib and paclitaxel: A potential diagnostic pitfall mimicking lichenoid drug eruptions associated with PDL-1 inhibitors.

Disseminated superficial actinic porokeratosis (DSAP) is an uncommon skin condition that can be inherited or may occur sporadically with multiple red-brown, thin plaques in a photodistribution. The condition more often affects middle-aged women and is often recalcitrant to therapy. In rare literature reports, systemic medications can trigger exacerbation or promote inflammation in pre-existing lesions of DSAP. We present a novel case of chemotherapy-associated DSAP inflammation in a 66-year-old woman after triple therapy with durvalumab (PD-L1 inhibitor), olaparib (PARP inhibitor) and paclitaxel, showing similarities to primary lichen planus-like eruption from immune checkpoint inhibitors.

Morphologic Forms and Classification of Dermal Mitotic Figure Density in Primary Cutaneous Melanoma: A Retrospective Study.

New American Joint Committee on Cancer eighth edition staging parameters have removed mitotic rate as a stage T1 category criterion, but it remains embedded in the synopsis of primary cutaneous melanoma (CM). A paucity of data is available, characterizing atypical mitotic forms in CM. In this study, we classify the various morphologic forms of atypical mitoses, characterize mitotic figure density, and examine the correlation between atypical mitotic figures and Breslow depth. We performed a retrospective study of 185 thick (>0.8 mm) and thin (<0.8 mm) CM specimens. Metaphase mitotic figures represented the highest percentage of total mitotic figures in cases of thick melanoma (40%) and were the second most common in thin melanoma (18%). The average Breslow depth for melanoma harboring starburst mitoses was 2.85 mm, compared with the average Breslow depth of all thick melanoma cases, 1.88 mm. The average thickness of melanoma cases containing tripolar mitoses was 2.28 mm. Breslow depth correlated with the number of atypical mitotic figures in both thick and thin melanomas (the Pearson correlation test, r = +0.18, P < 0.01). Metaphase and prophase mitoses are a common finding in both thick and thin melanomas. Although atypical mitoses were indiscriminate, starburst and tripolar (ie, multipolar) mitoses were only inherent to cases of thick melanoma (stage T3). In sum, our study reveals a parallel relationship between the density of atypical mitotic figures and Breslow depth.

Academics Versus Private Practice in Dermatology: a Junior Faculty's Perspective.

Young physicians at the end of their training must choose a career path from a variety of clinical care delivery models. The current medical curriculum lacks practical information regarding these practice settings. A rapidly changing health care landscape has fundamentally changed many practice types. An updated and current understanding of the different practice models is imperative for young physicians contemplating their career paths.

Systemic 5-fluorouracil induced lupus erythematosus: a review of the literature.

Drug-induced subacute cutaneous lupus erythematosus (SCLE) is the most common subtype of drug-induced systemic lupus erythematosus and has been associated with more than 100 drugs. It presents weeks to months after initiation of the culprit medication. The eruption is typically in a photodistribution and it is marked by positive serology to anti-Ro (SSA) antibody. Systemic 5-fluorouracil (5-FU) is a less-common culprit of drug-induced SCLE and its occurrence is likely dependent on exposure to ultraviolet light. Herein, we present a review of drug-induced lupus induced by the pyrimidine analog, 5-FU, and its prodrugs, capecitabine and uracil-tegafur. The search was carried out using the following terms: (PubMed: keywords included drug-induced lupus, 5-fluorouracil, subacute cutaneous lupus erythematosus, capecitabine, uracil-tegafur, discoid lupus, systemic lupus erythematosus).

Using Stratum Corneum Thickness and Configuration to Distinguish Lichenoid Dermatoses.

BACKGROUND: Clues in the stratum corneum (SC) can aide in histopathologic diagnosis of many conditions. OBJECTIVE: To determine if SC configuration and thickness could help differentiate the lichenoid dermatoses. METHODS: A retrospective study was performed. A total of 305 cases (55 lichenoid keratosis, 51 lichen planus, 7 hypertrophic lichen planus, 40 lichenoid drug eruption, 19 lichenoid graft-vs.-host disease, 14 hypertrophic lupus, 46 lichenoid actinic keratosis, 73 lentigo maligna) fulfilled the selection criteria. Cases were digitally scanned using the 40× (0.23 µm/pixel) mode of a Hamamatsu NanoZoomer 2.0-HT Slide Scanner (Hamamatsu Photonics, Hamamatsu City, Japan), allowing for the creation of virtual (digital) slides. SC thicknesses and configuration were assessed for each case. RESULTS: Mixed SC patterns were common in cases of lichenoid keratoses. Compact parakeratosis was the most common pattern in lichenoid drug eruption. Tiered parakeratosis was the most predominant pattern in cases of lichenoid graft versus host disease and lichenoid actinic keratosis. Hypertrophic lupus had the highest average SC thickness. LIMITATIONS: The sample size for cases of hypertrophic lupus and hypertrophic lichen planus was low. CONCLUSIONS: SC thickness and configuration can be utilized to help differentiate the lichenoid dermatoses.

Histiocyte-rich Discoid Lupus Erythematosus: A Peculiar Perifollicular Distribution Histologically Mimicking an Acneiform Disorder.

The histologic profile of discoid lupus erythematosus typically involves a vacuolar interface reaction with an associated superficial and deep perivascular infiltrate composed of lymphoplasmacytes. We present a unique case of discoid lupus erythematosus in which cluster of differentiation 68 (CD68) immunochemistry identified widely dispersed histiocytes. Few reports of histiocyte-rich cutaneous lupus erythematosus exist in the literature, and these lymphohistiocytic infiltrates, when present on the H-zone of the face, could be misconstrued as acne/rosacea. Our case demonstrates that cutaneous lupus erythematosus can present with a predominantly histiocytic infiltrate, a pattern dermatopathologists should be aware of to avoid non-recognition or misdiagnosis.

Molecular Variations in Histologic Subtypes of Basal Cell Carcinoma.

There are many molecular variations in the histologic subtypes of basal cell carcinoma (BCC); Ki67 and Bcl-2 expression differs among them and might relate to their prognostic features. The clinically notable friability and its histologic counterpart, retraction, are dependent on cell-cell adhesion and basement membrane characteristics, which may be altered in different ways depending on the tumor morphology and phenotype. Finally, we discuss the pathogenesis of BCCs and recent molecular advances with a review of new and upcoming molecular-based therapeutics.

Histopathologic Distinguishing Features Between Lupus and Lichenoid Keratosis on the Face.

BACKGROUND: The occurrence of lichenoid keratosis (LK) on the face is not well characterized, and the histopathologic distinction between LK and lupus erythematosus (LE) occurring on the face is often indeterminate. The authors aimed to describe differences between LE and LK occurring on the face by hematoxylin and eosin alone. METHODS: Cases of LK and LE were obtained using computer-driven queries. Clinical correlation was obtained for each lupus case. Other diagnoses were excluded for the LK cases. Hematoxylin and eosin-stained sections were reviewed. RESULTS: Forty-five cases of LK and 30 cases of LE occurring on the face were identified. Shared features included follicular involvement, epidermal atrophy, pigment incontinence, paucity of eosinophils, and basket-weave orthokeratosis. Major differences between LK and LE, respectively, included perivascular inflammation (11%, 90%), high Civatte bodies (44%, 7%), solar elastosis (84%, 33%), a predominate pattern of cell-poor vacuolar interface dermatitis (7%, 73%), compact follicular plugging (11%, 50%), hemorrhage (22%, 70%), mucin (0%, 77%), hypergranulosis (44%, 17%), and edema (7%, 60%). A predominate pattern of band-like lichenoid interface was seen more commonly in LK as compared with LE (93% vs. 27%). CONCLUSIONS: The authors established the occurrence of LK on the face and identified features to help distinguish LK from LE. Follicular involvement, basket-weave orthokeratosis, pigment incontinence, paucity of eosinophils, and epidermal atrophy were not reliable distinguishing features. Perivascular inflammation, cell-poor vacuolar interface, compact follicular plugging, mucin, hemorrhage, and edema favored LE. High Civatte bodies, band-like lichenoid interface, and solar elastosis favored LK.

Basal Cell Carcinoma. Part 1: Basal Cell Carcinoma Has Come of Age.

Almost 2 centuries after its recognition, basal cell carcinoma (BCC) remains the most common cancer worldwide, with a 30% overall lifetime risk in the United States and an incidence that continues to increase annually. The increasing incidence of BCC is multifactorial and likely correlates to multiple risk factors, including exposure to both ionizing and UV radiation. Despite its relatively indolent growth, what was once referred to as a rodent ulcer or basal cell epithelioma is now identified as a full-fledged malignancy. The authors describe the societal burden of this disease and characterize its malignant potential, emphasizing associated clinical and histopathologic prognostic features.

A Dermatopathologist's Guide to Troubleshooting Immunohistochemistry--Part 2: Troubleshooting Immunohistochemical Tests in the Laboratory.

Unexpected staining patterns can arise from problems occurring in any of the steps required for IHC, some of which are discussed in part I of this CME series. Whether used to differentiate benign from malignant tumors, identify tumor subtypes, subtypes of hematopoietic malignancies, or identifying targets for therapy, the pathologist must be intimately familiar with the potential pitfalls that are inherent in the IHC methodology to troubleshoot problems in the laboratory, and more importantly, when interpreting immunohistochemical staining, to avoid pitfalls of false-positive or false-negative stains.

A Dermatopathologist's Guide to Troubleshooting Immunohistochemistry Part 1: Methods and Pitfalls.

Immunohistochemistry (IHC) is a method by which specific target antigens can be detected in formalin-fixed paraffin-embedded tissue and involves the use of monoclonal or polyclonal antibodies; visualization of specific tissue antigens is achieved through an enzymatic reaction that transforms a colorless chromogen to a colored one. These enzymes may be attached to the antibody through a protein-ligand method (eg, biotin-avidin or biotin-streptavidin) or through a secondary antibody. Epitopes that are masked by protein linkage during formalin fixation are unmasked using a retrieval system that either uses heat (heat-induced epitope retrieval) or proteolytic enzymes (proteolytic-induced epitope retrieval). Part 1 of this review will focus and elaborate on the available methodologies for IHC testing, common problems inherent to each technique, and how they can be resolved. Part 2 will focus on common problems and artifacts encountered during IHC staining, likely causes, and methods for addressing each problem.