Negative predictive value of biopsy margins of dysplastic nevi: A single-institution retrospective review.

BACKGROUND: Biopsies of dysplastic nevi processed by bread-loafing allow for limited margin assessment; however, reported biopsy margins often influence management. OBJECTIVE: To evaluate the negative predictive value of biopsy margins of dysplastic nevi. METHODS: A retrospective search of a single academic institution's pathology database was conducted to identify all biopsy specimens of dysplastic nevi between January 1, 2015, and December 31, 2017. Biopsy specimen margin assessments were compared with excision pathology reports to calculate negative predictive value and to assess the frequency of residual nevus on excision after positive biopsy margins. RESULTS: A total of 1245 dysplastic nevi from 934 patients were identified. Clear biopsy margins had a negative predictive value for the absence of residual nevus on excision of 87.3% for dysplastic nevi of moderate atypia or greater. Residual nevus was identified on excision in 29.41% of cases of dysplastic nevi of moderate atypia or greater when initial biopsy margins were positive. LIMITATIONS: This was a retrospective, single-institution study. The calculations likely overestimate the true negative predictive value of biopsy margins because of processing of excision specimens by bread-loafing. CONCLUSIONS: This study provides additional evidence that reported biopsy margins are not representative of true margin status.

Pediatric ocular lichen planus and lichen planopilaris: One new case and a review of the literature.

When lichen planus involves the scalp, it is known as lichen planopilaris, and when it involves the eye, it is known as ocular lichen planus; both are rare. Early detection and targeted therapy are crucial in preventing hair loss and scarring conjunctivitis. Little is known regarding appropriate treatment for lichen planopilaris. The objective of this case study is to present a new case of pediatric ocular lichen planus and lichen planopilaris and to identify all reported cases of pediatric lichen planopilaris, highlighting disease involvement, treatment, and response to treatment.

Injection Site Necrosis and Ulceration Following Vaccination in an Adult Patient.

Local adverse reactions to vaccination are typically mild and often quickly resolve. Vaccine adjuvants such as aluminum salts in combination with improper vaccination technique may result in severe local adverse reactions. As far as we know, there is only one prior case of frankly necrotic rapidly progressing vaccine site necrosis, which occurred in a pediatric patient.1 To our knowledge, this is the first adult case of vaccine site necrosis to be reported. The presumed etiology has been aluminum salt adjuvants and improper vaccination technique. Here we present an adult case of a severe local reaction to a vaccine resulting in necrosis of the epidermis and dermis with central ulceration. Skin appendages were also involved, with necrosis of eccrine coils and hair follicles. This necrotic ulceration was likely due to robust inflammatory response to aluminum salt subcutaneous injection. Correct vaccine placement, needle size, and needle length may reduce adverse local skin reactions.

J Drugs Dermatol. 2018;17(3):364-367.

Chronic granulomatous dermatitis induced by talimogene laherparepvec therapy of melanoma metastases.

Talimogene laherparepvec (TVEC) is the first oncolytic viral immunotherapy approved by the FDA, for advanced melanoma consisting of genetically modified herpes simplex type 1 virus which selectively replicates causing tumor lysis, expressing granulocyte macrophage-colony stimulating factor (GM-CSF) and activating dendritic cells. Intratumoral injection of TVEC produces objective response in 41% of stage IIB-IV M1a melanoma. However, clinical response assessment can be problematic due to immune-related inflammation at established tumor sites. Herein, we report 5 cases of granulomatous dermatitis developing at sites of TVEC injection associated with pathologic complete response in 4 of 5 patients. Over 5 months, TVEC injections were administrated in a median of 20 tumors per patient for 9 median doses prior to biopsy of persistent, indurated nodules. Granulomatous dermatitis with melanophages and melanin pigment incontinence was observed in all samples without evidence of melanoma cells in 4 patients. The fifth patient was rendered melanoma-free by resection of the 1 nodule out of 4 with persistent tumor. Repetitive administration of TVEC or other oncolytic viral immunotherapies mimicking unresolved infection can produce granulomatous inflammation confounding assessment of the degree of tumor response and need for additional TVEC therapy. Tumor biopsies are encouraged after 4 to 6 months of TVEC administration to differentiate melanoma from granulomatous inflammation. Patients with confirmed granulomatous dermatitis replace continued with remained in remission after treatment discontinuation. Inflammatory nodules typically regress spontaneously.

Leishmaniasis Panamensis Masquerading as Myiasis and Sporotrichosis: A Clinical Pitfall.

We report a case of cutaneous leishmaniasis panamensis in nonendemic Costa Rica. A 19-year-old female presented with nonhealing, unilateral eruption of erythematous papules with superficial central ulceration in a sporotrichoid pattern on right upper arm and back. Given the clinical picture and geographic locale, the patient was initially diagnosed with myiasis or human botfly infestation; however, the sporotrichoid pattern of the bites is an unlikely finding in myiasis. Peripheral blood smear, Giemsa stain, and polymerase chain reaction (PCR) were consistent for Leishmania spp. Ulceration resolved with 20-day course of IV sodium stibogluconate.