Rapamycin for refractory discoid lupus erythematosus.

Generalized discoid lupus erythematosus can pose a therapeutic challenge for dermatologists. Current treatment emphasizes photoprotection, topical and systemic steroids, and steroid-sparing immunosuppressive agents if necessary. Rapamycin, also known as sirolimus, selectively inhibits mammalian target of rapamycin, a regulatory kinase responsible for multiple signal transduction pathways. Mammalian target of rapamycin inhibition reduces cell division, lymphocyte proliferation, cytokine release, and downstream pathways unique from other classes of immunomodulatory drugs. Herein, we present a case of generalized discoid lupus erythematosus resistant to topical steroids, prednisone, azathioprine, mycophenolate mofetil, hydroxychloroquine, and thalidomide. The addition of rapamycin led to a positive treatment response within 6 weeks, with good tolerance of the medication and no adverse effects. The current literature supporting the use of rapamycin in the treatment of autoimmune connective tissue diseases is also briefly reviewed. For patients with severe or generalized discoid lupus erythematosus refractory to conventional treatment, rapamycin may be a useful therapeutic consideration.

Impact of Mohs Micrographic Surgery on Tumor Staging of Cutaneous Squamous Cell Carcinoma: A Comparison of the 7th and 8th Editions of the American Joint Committee on Cancer Guidelines.

BACKGROUND: Based on current AJCC-7 guidelines for staging cutaneous squamous cell carcinoma (cSCC), patients with T2 tumor staging represent a prognostically heterogeneous group. The new AJCC-8 guidelines seek to provide improved stratification by inclusion of independent risk factors in the T3 category. These features may be identified in tissue stages during Mohs micrographic surgery (MMS). Thus, low-risk cSCC may be upstaged after MMS, impacting prognosis, additional evaluation, and adjuvant nonsurgical treatment. OBJECTIVE: To examine the impact of MMS on cSCC staging under AJCC-7 and AJCC-8 guidelines. MATERIALS AND METHODS: The medical record was queried for patients who underwent MMS for cSCC. Data were recorded for 190 MMS specimens and corresponding biopsies. Tumor staging according to AJCC-7 and AJCC-8 was assigned. RESULTS: High-risk histologic features are more likely identified with MMS than biopsies. Cutaneous squamous cell carcinoma was equally likely to be upstaged during MMS under both AJCC-7 and AJCC-8, with 10.5% being classified as AJCC-8 T3. Seventy percent of these were only classified as T3 after MMS. Upstaging to T3 during MMS under AJCC-8 is less likely than upstaging to T2 under AJCC-7. CONCLUSION: Mohs surgeons have a significant impact on accurate staging of high-risk cSCC. AJCC-8 improves risk stratification of cSCC.

Subacute cutaneous lupus erythematosus presenting in twins.

Subacute cutaneous lupus erythematosus is a clinically distinct form of cutaneous lupus erythematosus, with age of onset typically in the second to fifth decades. Eleven cases have been reported in childhood, and we present the first known case of subacute cutaneous lupus erythematosus in identical twins. Although flares are typically photo-induced, we present an annular eruption typical of subacute cutaneous lupus erythematosus with concurrent pinworm infestation, with recurrence of disease with cutaneous larva migrans. The patient's identical twin had a similar eruption with pinworm infection. This case highlights the possibility of parasitic infestation as a trigger for subacute cutaneous lupus erythematosus in genetically susceptible individuals.

An algorithm for management of deep brain stimulation battery replacements: devising a web-based battery estimator and clinical symptom approach.

OBJECTIVE: Deep brain stimulation (DBS) is an effective technique that has been utilized to treat advanced and medication-refractory movement and psychiatric disorders. In order to avoid implanted pulse generator (IPG) failure and consequent adverse symptoms, a better understanding of IPG battery longevity and management is necessary. BACKGROUND: Existing methods for battery estimation lack the specificity required for clinical incorporation. Technical challenges prevent higher accuracy longevity estimations, and a better approach to managing end of DBS battery life is needed. METHODS: The literature was reviewed and DBS battery estimators were constructed by the authors and made available on the web at http://mdc.mbi.ufl.edu/surgery/dbs-battery-estimator. A clinical algorithm for management of DBS battery life was constructed. The algorithm takes into account battery estimations and clinical symptoms. RESULTS: Existing methods of DBS battery life estimation utilize an interpolation of averaged current drains to calculate how long a battery will last. Unfortunately, this technique can only provide general approximations. There are inherent errors in this technique, and these errors compound with each iteration of the battery estimation. Some of these errors cannot be accounted for in the estimation process, and some of the errors stem from device variation, battery voltage dependence, battery usage, battery chemistry, impedance fluctuations, interpolation error, usage patterns, and self-discharge. We present web-based battery estimators along with an algorithm for clinical management. We discuss the perils of using a battery estimator without taking into account the clinical picture. CONCLUSION: Future work will be needed to provide more reliable management of implanted device batteries; however, implementation of a clinical algorithm that accounts for both estimated battery life and for patient symptoms should improve the care of DBS patients.