Long-Term Outcomes of Melanoma In Situ Treated With Topical 5% Imiquimod Cream: A Retrospective Review.

BACKGROUND: Melanoma in situ (MIS) is a noninvasive form of melanoma for which nonsurgical therapeutic options continue to be explored. The off-label use of topical 5% imiquimod cream in the management of MIS has shown potential but reported recurrence rates vary considerably between 0% and 40%. Furthermore, the long-term efficacy of imiquimod is not well established. OBJECTIVE: To determine the recurrence rate of MIS among patients treated with topical 5% imiquimod cream at Dartmouth-Hitchcock Medical Center with at least 1 year of follow-up. METHODS: A retrospective chart review identified 12 patients with MIS who have been treated with topical 5% imiquimod cream for 6 to 12 weeks. Patients who underwent surgical treatment for MIS were excluded from analysis. RESULTS: Of 12 patients with histologically confirmed MIS treated with topical 5% imiquimod cream, there were 2 recurrences (17%) during a median follow-up time of 5.5 years. CONCLUSION: Although surgery is still considered the gold standard for the treatment of MIS, imiquimod may represent a potentially effective noninvasive treatment option for patient who are not surgical candidates.

Patient-provider communication, concordance, and ratings of care in dermatology: Results of a cross-sectional study.

ObjectiveTo determine the impact of race concordance on patient perception of quality of dermatologic care.Study designCross-sectional study.SettingAcademic outpatient practices in the Departments of Dermatology of Eastern Virginia Medical School and the Johns Hopkins University School of Medicine.ParticipantsThe study cohort comprised 124 participants including 6 providers and 118 established patients.Main Outcome MeasuresWe hypothesized, a priori, that patients in race-discordant dyads would report lower ratings of participatory decision-making (PDM), satisfaction, trust in the provider, and similarities with providers.ResultsPatients in race-discordant dyads reported less positive ratings on 4 out of 8 participatory decision-making questionnaire items (p values < 0.05), and were significantly more likely to perceive differences with providers in race and culture (p values < 0.05). These differences persisted to varying degrees after controlling for key confounders such as education and income level. Participants in race-concordant and race-discordant dyads did not differ in their perceptions of satisfaction or trust.ConclusionsPatient perception of participation in the decision-making process and of shared similarities with their providers is attributable in varying degrees to race concordance. Continued strengthening of cultural competency skills during medical and dermatology residency training as well as increased diversification of the dermatologic workforce could attenuate the adverse influences of race discordance and other socioeconomic factors on patient-provider communication.

Secondary cutaneous marginal zone B-cell lymphoma presenting as lipoatrophy in a patient with hepatitis C.

BACKGROUND: Hepatitis C viral infection is a significant public health problem; 170 million persons are infected worldwide and the prevalence in the southern part of the United States exceeds two percent. Extrahepatic manifestations of hepatitis C viral infection are common; notably, 15-20% of patients will develop cutaneous manifestations of their disease. There are numerous dermatologic diseases associated with hepatitis C infection, including lichen planus, leukocytoclasticvasculitis, and porphyria cutaneatarda. MAIN OBSERVATION: Recently, epidemiological studies have also demonstrated an association between hepatitis C infection and the development of non-Hodgkin lymphoma, especially marginal zone B-cell lymphoma. Herein we report the unusual case of a systemic marginal zone lymphoma in a patient with hepatitis C infection presenting clinically as localized lipoatrophy. CONCLUSIONS: Lipoatrophy can be a rare and diagnostically challenging presentation of secondary cutaneous marginal zone B-cell lymphoma. The importance of early recognition and detection cannot be over emphasized, as new and effective anti-viral treatments can lead to lymphoma regression in up to 75% of patients. To our knowledge, this is the first case of hepatitis C viral infection associated marginal zone lymphoma to present as localized lipoatrophy.

Changing age distribution of melanoma patients: a 22-year, single-site perspective.

OBJECTIVES: To investigate possible changes in the demographics of patients with melanoma during a period of 22 years in one dermatopathology practice. METHODS: We performed a retrospective review of 1835 cases of in situ and invasive melanomas histologically diagnosed between 1989 and 2010 in a private dermatopathology laboratory in Norfolk, Virginia. The age and sex of patients with in situ and invasive melanomas were recorded and compared with similar data for patients from whom any histopathologic specimen was received during the same interval. These data were then compared with those in the national Surveillance, Epidemiology, and End Results (SEER) registry between 1989 and 2009. RESULTS: The number of melanomas diagnosed in the laboratory increased during the 22 study years, but the proportion of submitted specimens diagnosed as melanoma remained somewhat stable. Patient ages ranged from the teens to the ninth decade of life. The proportion of melanomas in the in situ stage gradually increased. Mean patient age rose from 52.4 years in 1989 to 60.7 years in 2010. Men and women aged 60 years and older made up an increasing proportion of melanoma cases. There also was a relative increase in the proportion of women in the 40- to 50-year-old age group and a slight increase among those aged 20 to 30 years, particularly for invasive lesions. In general, the trends were similar for in situ and invasive melanomas. Our data were consistent with the SEER data in showing a trend for decreasing proportion of melanomas in younger individuals, with a corresponding increase in the middle-age and older adult populations. Some differences between the two datasets emerged for men aged 70 to 80, women aged 60 to 70, and all patients aged 70 to 80. CONCLUSIONS: An increasing proportion of melanomas were diagnosed in older individuals. There also was a relative increase in women aged 40 to 50 years and a lesser increase in those aged 20 to 30 years. Our findings were consistent with the national trends observed in the SEER dataset.

A double-blind, randomized, placebo-controlled trial of adalimumab in the treatment of cutaneous sarcoidosis.

BACKGROUND: Many medications, including tumor necrosis factor antagonists, have been anecdotally reported to be effective in treating cutaneous sarcoidosis, but controlled study is lacking. OBJECTIVE: We sought to determine if adalimumab is a safe and effective treatment for cutaneous sarcoidosis. METHODS: Adalimumab or placebo was administered to 10 and 6 patients, respectively, in double-blind, randomized fashion for 12 weeks, followed by open-label treatment for an additional 12 weeks, followed by 8 weeks of no treatment. Assessments were made of cutaneous lesions, quality-of-life issues, laboratory findings, pulmonary function, and radiographic findings. RESULTS: At the end of the 12-week, double-blind phase, there was improvement in a number of cutaneous findings in the adalimumab-treated patients (group 1) relative to placebo recipients (group 2), most notably in target lesion area (P = .0203). At the end of the additional 12-week open-label phase, significant improvement relative to baseline was found for target lesion area (P = .0063), target lesion volume (P = .0225), and Dermatology Life Quality Index score (P = .0034). No significant changes were seen in pulmonary function tests, radiographic findings, or laboratory studies. After 8 weeks off treatment, there was some loss of this improvement. LIMITATIONS: Standardized, validated measures for cutaneous sarcoidosis are lacking. There may be observer bias in the open-label portion of this study. The small size of this study makes it difficult to generalize results. CONCLUSIONS: Adalimumab, at the dose and duration of treatment used in this study, is likely to be an effective and relatively safe suppressive treatment for cutaneous sarcoidosis.

An open-label pilot study of apremilast for the treatment of moderate to severe lichen planus: a case series.

BACKGROUND: Current treatments for chronic lichen planus (LP) are often ineffective and may have significant adverse side effects. An alternative safe and effective treatment for recalcitrant LP is needed. OBJECTIVES: We sought to study the safety and efficacy of apremilast in the treatment of moderate to severe LP. METHODS: Ten patients with biopsy-proven LP received 20 mg of apremilast orally twice daily for 12 weeks with 4 weeks of treatment-free follow-up. The primary efficacy end point was the proportion of patients achieving a 2-grade or more improvement in the Physician Global Assessment (PGA) after 12 weeks of treatment. RESULTS: Three (30%) of the 10 patients achieved a 2-grade or more improvement in the PGA after 12 weeks of treatment; however, all patients demonstrated statistically significant clinical improvement with respect to secondary parameters between baseline and the end of treatment. LIMITATIONS: It may be difficult to generalize the results of this study to a larger patient population with LP because of our small sample size and lack of a control group. In addition, a longer treatment period or higher dose may have been needed for therapeutic efficacy. The safety and efficacy of long-term apremilast therapy is currently unknown. CONCLUSION: Apremilast may be efficacious in the treatment of LP, but double-blinded, controlled trials are necessary to thoroughly evaluate its safety and efficacy.

Treated Whipple disease with erythema nodosum leprosum-like lesions: cutaneous PAS-positive macrophages slowly decrease with time and are associated with lymphangiectases: a case report.

Pathologically, Whipple disease (WD) is characterized by the accumulation of myriad macrophages parasitized by Tropheryma whipplei (TW) bacilli denoted by periodic acid-Schiff (PAS) positivity. These PAS+ macrophages are typically found in the duodenum associated with lymphangiectasia. Recently, we reported the presence of PAS+ macrophages and free TW in erythema nodosum leprosum (ENL)-like lesions and normal skin in a patient with WD who suffered from the immune reconstitution inflammatory syndrome (IRIS). We extend that report by describing the clinical and pathologic findings over 5 years of follow-up. First, the IRIS gradually diminished and abated over 18-month time. Second, at no point did WD recur, and all duodenal and skin biopsies tested by polymerase chain reaction were negative for TW DNA. Third, PAS+ macrophages were identified in 26 of 27 skin biopsies (96%) and decreased along with free TW over time. Fourth, ENL-like lesions had significantly greater numbers of PAS+ macrophages than normal skin. Moreover, normal abdominal skin (region of ENL-like lesions) had greater PAS+ counts than arm skin (not a site of IRIS). Last, lymphangiectases, a histologic sign of lymphostasis, was found in all skin biopsies. Overall, these findings implicate bacillary burden as a factor in the immune tolerance to live TW in active WD and the initiation of ENL-like nodules against dead/nonreplicative TW in treated WD. In addition, poor lymphatic drainage is likely responsible for the gradual clearance of TW from the skin and the impaired delayed-type hypersensitivity reaction (absence of activated macrophages) against TW found in WD, presumptively due to reduced/absent immune cell trafficking necessary for lymphocyte-macrophage interactions and induction of adaptive immunity.

Lymphangiectases are common underlying warts and in normal peritumoral skin: histologic evidence of decreased immune surveillance.

BACKGROUND: Lymphangiectases are a histologic sign of lymphostasis, which is associated with decreased immune cell trafficking and cell-mediated immunity. OBJECTIVE: To determine if latent lymphedema is apparent underlying warts and in skin affected by cutaneous neoplasia. MATERIALS AND METHODS: The number and maximal dilation of lymphangiectases were measured in the upper half of the dermis of 51 consecutive biopsies of warts, 230 consecutive normal skin samples from primary skin tumor excisions, and 14 normal skin samples from breast reduction (11) and panniculectomy (3) specimens. RESULTS: All warts had one or more underlying lymphangiectases compared with 79% of peritumor normal skin samples and 50% of cosmetic specimens. The mean number of lymphangiectases and mean maximal dilation were significantly greater in warts than in peritumor skin, which was significantly greater than cosmetic skin samples (3.6 vs. 1.3 vs. 0.12 lymphangiectases per square millimeter and 54 vs. 23 vs. 1 µm, respectively; P = 0.0001). Warts exhibited mild fibrosis significantly more frequently than peritumor skin (57% vs. 5%; P = 0.0001). For peritumor (normal) skin, age, solar elastosis, and adjacent malignancy correlated with greater dilation of lymphatics. Solar elastosis also correlated with increased number of lymphangiectases. CONCLUSIONS: Minor trauma and solar elastosis from chronic ultraviolet radiation exposure are likely the etiologic factors in the development of lymphostasis. By decreasing immune surveillance, latent lymphedema ostensibly facilitates human papillomavirus infection and carcinogenesis.