Idiopathic Facial Aseptic Granuloma: Review of an Evolving Clinical Entity.

Idiopathic facial aseptic granuloma (IFAG), originally termed pyodermite froide du visage, describes a generally asymptomatic facial nodule presenting in childhood with clinical resemblance to pyoderma or cystic, granulomatous, or vascular lesions. Clinical understanding is constantly evolving, with recent observations indicating that IFAG may represent a subtype of childhood rosacea. We present a case of IFAG associated with eyelid chalazions in a 19-month-old boy. Although his clinical course paralleled previously reported IFAG cases, we observed a unique ultrasound variation during initial diagnostic examination. Further delineation of clinical, imaging, and histologic properties of IFAG may reveal insights into etiologic associations and ideal management.

Eosinophilic folliculitis occurring after stem cell transplant for acute lymphoblastic leukemia: a case report and review.

BACKGROUND: Eosinophilic folliculitis (EF) comprises classic eosinophilic pustular folliculitis (EPF), human immunodeficiency virus (HIV)-related EF, and infantile EPF subtypes. A fourth proposed subtype describes EF associated with hematologic malignancy. Recently, EF has occurred after bone marrow or stem cell transplantation (SCT). OBJECTIVES: We report a unique case of EF after haploidentical allogeneic SCT for acute lymphoblastic leukemia (ALL) and review the literature for similar cases. METHODS: A 56-year-old, HIV-negative ALL patient presented with an intensely pruritic papulopustular eruption. He had undergone haploidentical allogeneic SCT 65 days earlier, which he had tolerated well. Histopathology revealed a moderately dense perifollicular and perivascular lymphocytic infiltrate with many eosinophils extending from the superficial dermis to the subcutaneous fat. Fungal stains were negative. These findings were highly consistent with EF. RESULTS: Therapy with a class II topical corticosteroid ointment, oral doxepin, and emollients achieved near-resolution of the lesions within eight weeks. Transition to topical tacrolimus 0.1% ointment applied twice daily to residual lesions yielded complete clearance by 12 weeks with mild post-inflammatory hyperpigmentation. The patient's ALL remains in remission. CONCLUSIONS: A fourth proposed subtype of EF is associated with HIV-negative hematologic disease. This subtype is distinguished by a predictable timeframe to presentation and a relatively rapid response to therapy. Although EF is an important consideration in all patients with hematologic malignancy, clinically heightened suspicion is warranted during the 2-3 months after transplant.

Psoriasis first presenting around an enteral feeding tube in three pediatric patients: an important consideration for timely diagnosis and management.

Pediatric dermatologists may care for patients with percutaneous enteral feeding tubes. Although ostomy complications such as allergic contact and irritant dermatitis are common, psoriasis may be misdiagnosed. We report three novel cases of childhood psoriasis first presenting around an enteral feeding tube site. Localized psoriasis is an important clinical consideration in children with ostomy site eruptions to ensure timely diagnosis and effective management.

Squamous cell carcinoma of the lip associated with adalimumab therapy for ankylosing spondylitis: a case report and review of TNF-α inhibitors and cutaneous carcinoma risk.

Adalimumab is an anti-tumor necrosis factor α (TNF-α) agent approved for the treatment of ankylosing spondylitis (AS); psoriatic arthritis; and moderate to severe cases of rheumatoid arthritis (RA), plaque psoriasis, Crohn disease, ulcerative colitis, and polyarticular juvenile idiopathic arthritis. Evidence suggests that anti-TNF-α agents may increase a patient's risk for some types of cancers, including cutaneous squamous cell carcinoma (SCC). Cutaneous nonmelanoma skin cancers (NMSCs) have occurred during treatment with etanercept, infliximab, and adalimumab in the setting of RA and psoriasis, but data related to AS are less clear. We report the case of a 29-year-old woman with AS treated with adalimumab for 2 years who developed invasive SCC of the lower lip. We advocate increased NMSC surveillance in patients undergoing treatment with anti-TNF-α agents.

Resident rounds. Part III: case report: temporary traumatic discoloration from handling moss-covered firewood.

Pattern recognition remains a valuable tool in the accurate diagnosis of dermatologic disease. A comprehensive patient history and physical examination denote cornerstones of medical evaluation, and in our specialty, dermoscopy can supplement data gathering to allocate cutaneous eruptions into appropriate categories. We present a case of acute onset palmar discoloration occurring in an otherwise healthy patient. Correct diagnosis transpired in the clinical setting with tailored questioning based on careful examination and adjunct dermatoscopic evaluation.

Progressive multifocal leukoencephalopathy and reversible progressive leukoencephalopathy syndrome in dermatologic therapy.

Progressive multifocal leukoencephalopathy (PML) is a frequently fatal demyelinating disease of the brain caused by activation of the John Cunningham virus. It typically occurs in immunocompromised patients, including transplant recipients on immunosuppressant medications, patients receiving chemotherapy for hematologic malignancies, and patients with human immunodeficiency virus. Unfortunately, there is no effective treatment for PML. By contrast, reversible progressive leukoencephalopathy syndrome (RPLS) is a generally treatable disorder that is diagnosed based on clinical symptoms (eg, altered mental status, visual abnormalities, headache, and seizures) and neuroradiographic changes (eg, cerebral edema). It is classically associated with malignant hypertension and immunosuppressive medications. Symptoms usually resolve over time, or with treatment of the underlying cause. Amid the relatively recent withdrawal of efalizumab from the US market because of its association with PML, and the added warning found on ustekinumab describing RPLS as a possible adverse effect, there has been an increasing level of concern in dermatology that biologics and other systemic medications used in the treatment of psoriasis may be related to an increased risk of specific leukoencephalopathies. In this review, we evaluate the association of prebiologics (eg, cyclosporine, methotrexate, acitretin) and biologics (eg, adalimumab, alefacept, efalizumab, etanercept, infliximab, rituximab, and ustekinumab) with the potential risk of developing PML and RPLS.

Intralesional injections of alefacept may predict systemic response to intramuscular alefacept: results from a pilot study.

BACKGROUND: Alefacept (Amevive®) was the first biologic agent to be approved by the FDA for use in moderate to severe chronic plaque psoriasis and remains one of the safest systemic agents. However, alefacept is the least utilized of all the biologic agents due to the finding that it is only effective in a small proportion of patients and its maximal efficacy is not seen until approximately 6 weeks after treatment completion. OBJECTIVE: To determine whether intralesional injections with a biologic agent can predict who will be a responder or a non-responder to the medication. METHODS: This was a single-center 22-week study consisting of three phases: i) intralesional injection to a target plaque, ii) intramuscular alefacept injections for 12 weeks (standard dose) and iii) post-treatment follow-up. RESULTS: There appears to be a perfect correlation between patients who show a response to an intralesional injection of alefacept to a small, target plaque and those who eventually respond to a full 12-week systemic course of the medication (achieve at least 70% improvement in their PASI scores from baseline) (p = 0.0003). LIMITATIONS: This study had a small sample size and was limited by the fact that it was open-label without a control arm. CONCLUSION: The results from this pilot study demonstrated that alefacept appears to work intralesionally and this may be usable to predict systemic response. More importantly, these results strongly suggest that a biologic agent can work locally - a novel concept that contradicts the common notion that biologic agents must work "systemically".

Evidence-based evaluation and management of chronic urticaria in children.

Urticaria affects nearly 25% of the population at some time in their lives. In a subset of children, urticaria will develop into a chronic condition that can greatly affect quality of life. Although numerous causes and triggers are proposed for chronic urticaria (CU) in children, ranging from infections, allergens, and medications to physical factors and autoimmune disease, the exact etiology is not always identifiable. Accordingly, a large subset of cases are designated "chronic idiopathic urticaria." Because of the clinical complexities of CU, as well as the confusing literature on this topic, we have developed a conceptual framework based on the cumulative evidence to assist with the categorization, clinical evaluation, and treatment of CU in children.

Yin-yang strategy: proposing a new, effective, repeatable, sequential therapy for psoriasis.

Psoriasis is a chronic disease that exists in two phases: (1) the acute, flaring phase when psoriasis is highly inflamed, erythematous and pruritic and (2) the chronic, indolent phase after the acute manifestations are brought under control. Ideal therapies for psoriasis must focus on both of these phases. Therefore, a rapid and effective agent must be utilized to treat the acute phase, followed by safe long-term therapy for maintenance. This article proposes a new, effective sequential topical therapy for psoriasis using ongoing treatment with clobetasol (Clobex®) spray for one month followed by calcitriol (Vectical®) ointment for the next month. This strategy provides a highly effective, reliable and safe treatment option with minimal local and systemic adverse risks.