Acute generalized exanthematous pustulosis associated with ranolazine.

Acute generalized exanthematous pustulosis (AGEP) is a potentially widespread, pustular, cutaneous eruption commonly associated with drug administration. We report a case of AGEP associated with the antianginal, anti-ischemic agent ranolazine. The patient, an 83-year-old man, had a validation score of 10 out of 12 in accordance with the EuroSCAR criteria (8-12 is considered definitive), although it may have been higher had blood work been performed prior to diagnosis and treatment. After ranolazine was discontinued and a course of tapered oral prednisone was prescribed, the rash resolved with subsequent desquamation.

Incidence of residual nonmelanoma skin cancer in excisions after shave biopsy.

BACKGROUND: Nonmelanoma skin cancer is an increasingly common disease that is typically treated surgically. After histopathologic confirmation by biopsy, the carcinoma is typically removed by excision, but not all excisional specimens contain residual carcinoma. OBJECTIVES: To define the rate of residual basal and squamous cell carcinomas within excisional specimens after shave biopsy in a general dermatology office. METHODS: We retrospectively reviewed 439 consecutive cases sent to a single dermatopathology lab from a practitioner's general dermatology office who also performs Mohs micrographic surgery. One hundred cases had a histopathologically proven carcinoma on biopsy with subsequent excision. Histopathologic type, location, age, sex, and time from biopsy to excision were all analyzed for statistical association. RESULTS: Of 57 cases of basal cell carcinoma, 34 (59.6%) had positive residuals. Of 43 cases of squamous cell carcinoma, 12 (27.9%) had positive residuals. Histologic type was significantly associated (p = .002) with residual carcinoma in excisional specimens, with basal cells 2.13 times as likely to have residual carcinoma present. CONCLUSION: The rate of residual nonmelanoma carcinoma in excision specimens after shave biopsy was found to be different from previously reported in the literature. These data may have therapeutic ramifications if further substantiated.

The safety and efficacy of fractional photothermolysis for the correction of striae distensae.

BACKGROUND: Improving the appearance of striae distensae, particularly striae alba, has remained a challenge due to the limited availability of effective and low-risk treatment options. Fractional photothermolysis, a novel concept in skin rejuvenation, has been reported to be effective in the treatment of facial rhytides, acne scars, and surgical scars, but its use in the treatment of striae has not been well studied. OBJECTIVE: To determine the safety and efficacy of fractional photothermolysis treatment on striae alba and striae rubra. METHODS: Twenty female patients with striae rubra or striae alba on their abdomen, thighs, or buttocks were enrolled in the study. Lesions were randomized to receive treatment, with site-matched normal control areas. Patients received a total of 6 treatments using a 1550-nm, erbium-doped fiber laser with 2 to 3 weeks of elapsed time between treatments. Clinical response to treatment was assessed at each visit, and at 1-month, 2-month, and 3-month follow-up intervals by the patient and investigator. A comparison evaluation of 8 patients examining photographs of striae at baseline and at the 3-month follow-up evaluation which was assessed by 4 independent dermatologists using the quartile grading scale. RESULTS: The independent evaluators' assessments of improvement from photographs of 8 randomly selected patients showed an overall improvement of 26% to 50% in 63% (5/8) of patients. A less than 25% improvement in dyschromia was noted in 50% (4/8) of patients. An improvement in texture of 26% to 50% was observed in 50% (4/8) of patients. The clinical responses were independent of age, gender, and skin phototype. The treatments were tolerated well by all patients with a majority of patients experiencing transient posttreatment erythema and edema. CONCLUSION: Fractional photothermolysis can be effectively and safely used in the treatment of striae rubra and striae alba.

Thermage: the nonablative radiofrequency for rejuvenation.

Thermage is a noninvasive nonablative device that uses monopolar radiofrequency energy to bulk heat underlying skin while protecting the epidermis to produce skin tightening. It is used for the treatment of rhytids on the face including the periorbital region and lower face, and more recently, for off-face applications. Studies have shown that it can impart mild tightening of periorbital mid, and lower facial laxity. Other radiofrequency devices have also shown objective improvements in cellulite of the buttocks and thigh regions. Thermage is an efficacious and safe nonsurgical alternative for treating mild skin laxity.

Eyelid tightening and improved eyelid aperture through nonablative fractional resurfacing.

BACKGROUND AND OBJECTIVE: The effects of fractional resurfacing on eyelid tightening and aperture are unknown. Our purpose was to retrospectively examine the potential for eyelid tightening and eye-aperture opening in patients treated with nonablative fractional resurfacing for facial photorejuvenation. STUDY DESIGN/MATERIALS AND METHODS: Fractional laser treatments using a 1,550-nm erbium-doped fiber laser system on the upper and lower eyelids were given at a pulse energy of 17 to 20 mJ at 125 micro-thermal zones (MTZ)/cm(2) to a final density of 500 to 750 MTZ/cm(2). Each patient had 3 to 7 treatments. Standard pre- and post-treatment photographs were taken at each visit. Physicians who graded 31 preselected patient photographs using a 4-point scale evaluated eyelid tightening. Increase in eyelid aperture was also evaluated. RESULTS: All patients had some degree of eyelid tightening; 19% achieved 1% to 25% tightening, 26% achieved 25% to 50%, 26% achieved 50% to 75%, and 29% achieved 75% to 100%. Increase in eyelid aperture was seen in 55.9% of patients. Postoperative wounding, hypopigmentation, hyperpigmentation, persistent erythema, and scarring were not observed. All patients experienced mild or no edema for a few days after treatment. CONCLUSION: Fractional resurfacing tightens and increases eyelid aperture without wounding, downtime, or long-term complications.

Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing.

BACKGROUND: Acneiform scarring after severe episodes of acne is a common cosmetic concern, treatable by a variety of modalities with varying degrees of success. Ablative CO(2) laser resurfacing, while effective, is associated with an undesirable side effects profile, lengthy recovery period, and risk of infection as well as potential pigmentary alterations. Newer modalities using the principles of fractional photothermolysis (FP) create patterns of tiny microscopic wounds surrounded by undamaged tissue beneath the skin with an erbium-doped 1,550 nm laser. These devices produce more modest results in many cases than traditional carbon dioxide (CO(2)) lasers but with fewer side effects and shorter recovery periods. A novel ablative 30 W CO(2) laser device uses a technique called ablative fractional resurfacing (AFR), combines CO(2) ablation with a FP system. METHODS: Thirteen subjects (skin types I-IV, aged 28-58 years) with moderate to severe acne scars underwent two or three treatments with the AFR device at 1-2 months intervals. Post-treatment erythema and edema as well as improvements in texture, atrophy, and overall satisfaction with appearance were graded on a quartile scale by subjects and investigators after each treatment and 1 and 3 months after the final treatment. Petechiae, oozing and crusting, dyschromia, and scarring were graded as present or absent 3 days, 1 week, 1 month, and 3 months following each treatment. A three-dimensional optical profiling system (Primos imaging) was used to generate a high resolution topographic representation of the acneiform scar in order to measure the depths of 10 scars from each cheek prior to the first treatment and 3 months after the last treatment. RESULTS: Post-treatment side effects were mild to moderate and transient, resolving rapidly within the study period. No delayed onset hypo-pigmentation or permanent scarring was observed. Quartile grading scores correlating to at least 26-50% improvements in texture, atrophy, and overall improvement were noted in all patients. Primos topographic analysis showed that all patients had quantifiable objective improvement in the depths of acneiform scars that ranged from 43% to 79.9% with a mean level of improvement of 66.8%. CONCLUSION: Successfully combining ablative technology with FP, AFR treatments constitute a safe and effective treatment modality for acneiform scarring.

Etanercept and demyelinating disease in a patient with psoriasis.

The tumor necrosis factor-alpha antagonist (TNF-alpha) etanercept has been approved for the treatment of rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis. Earlier reports on the use of etanercept or infliximab in patients with rheumatoid arthritis, psoriatic arthritis, or juvenile rheumatoid arthritis suggested an increased risk of demyelinating disease. It is imperative that dermatologists have a keen awareness of this possible adverse event given the increased use of this class of drugs. We report a case of demyelinating disease occurring in a patient treated for psoriasis. The relation of TNF-alpha antagonist therapy to demyelinating disease/multiple sclerosis is explored. It is recommended that patients be diligently screened before starting TNF-alpha antagonist therapy and that vigilance for symptoms of demyelinating disease/multiple sclerosis be included in follow-up examinations during treatment with these drugs.

Clinical application of dynamic telepathology in Mohs surgery.

BACKGROUND: Telepathology is an expanding technology in multiple fields for remote pathology diagnosis and consultation. The use of telepathology in Mohs surgery has been very limited. OBJECTIVE: To describe the clinical experience of using a telepathology system for intraoperative consultations on difficult frozen sections during Mohs surgery. MATERIALS AND METHODS: Intraoperative consultation with a dermatopathologist was obtained using a dynamic telepathology system for all questions arising on frozen sections during Mohs surgery for nonmelanoma skin cancers during a 2-year period. RESULTS: The most common reason for consultation was to distinguish basal cell carcinoma from a benign histologic simulant on Mohs frozen sections. Other uses included determining tumor histology and distinguishing inflammation from residual tumor. CONCLUSION: Dynamic telepathology is a useful and convenient adjunct in the Mohs surgery practice for intraoperative consultations on difficult frozen sections.

Innovative laboratory techniques to facilitate processing of large Mohs cases.

BACKGROUND: Processing multiple tissue sections in large Mohs cases is time consuming and labor intensive. OBJECTIVE: To present innovative laboratory techniques to facilitate processing of large Mohs cases. METHODS: A method for processing a large dermatofibrosarcoma protuberans Mohs case is outlined. RESULTS: Modifications in tissue processing and equipment employed in a large Mohs case are presented. CONCLUSION: Innovative modifications to the standard Mohs laboratory technique can facilitate processing of large Mohs cases, resulting in high-quality, rapid frozen sections while optimizing efficiency.