Serum triamcinolone levels during intensive, inpatient wet-dressing therapy.

BACKGROUND: Wet dressings combined with topical corticosteroids are beneficial for patients with generalized and refractory dermatosis; however, to our knowledge, serum levels after topical corticosteroid absorption during intensive therapy have not been reported previously. AIM: To examine serum levels of triamcinolone acetonide (TAC) after topical corticosteroid application during intensive wet-dressing therapy. METHODS: We performed a retrospective study of adult patients admitted for inpatient wet-dressing therapy from 7 November 2015 to 24 June 2016. Data were collected on sex, age, body surface area, TAC serum levels, number of wet-dressing changes after 24 and 48 h, and type of wet dressing. RESULTS: In total, 29 patients (14 men, 15 women) were assessed. Median [interquartile range (IQR)] age was 57 years (51.5-67.0 years) and involved body surface area was 1.98 m2 (1.88-2.15) m2 . Before the 24-hour blood draw, patients had received 1-3 dressing changes. Median (IQR) TAC level at 24 h was 0.33 µg/dL (0.20-0.58 µg/dL), with no significant difference noted between the number of dressing changes and TAC serum level. At 48 h, results of a serum TAC test were available for 22 patients with 2-6 dressing changes. Mean (IQR) serum level was 0.30 µg/dL (0.30-0.87 µg/dL). For each additional dressing change, there was an estimated 0.21 µg/dL increase in TAC serum level (95% CI 0.11-0.31; P < 0.001). TAC serum level was not significantly associated with sex, age, body surface area or dressing type. CONCLUSIONS: Intensive, inpatient wet-dressing therapy is associated with detectable TAC serum levels. However, we suspect that topical TAC has a primarily local therapeutic effect on the skin.

Differential expression of interferon-induced genes and other tissue-based biomarkers in acute graft-versus-host disease vs. lupus erythematosus in skin.

BACKGROUND: In both acute graft-versus-host disease (GVHD) and lupus erythematosus (LE), the patient's own tissues are subjected to immunological assault via complex mechanisms influenced by interferon (IFN) and other cytokines. Although not typically confused clinically, these entities have overlapping histopathological findings in the skin. AIM: To assess whether GVHD can be differentiated from LE using molecular methods on skin specimens. METHODS: We developed a quantitative reverse transcription PCR assay based on previously identified tissue-based biomarkers of cutaneous GVHD, and compared gene expression in GVHD with that in LE. RESULTS: Both entities showed robust expression of IFN-induced genes and of genes encoding proteins involved in antigen presentation, cell signalling and tissue repair. Levels of gene expression differed significantly in GVHD compared with LE, particularly those of IFN-induced genes such as MX1, OAS3, TAP1 and STAT3 (P < 0.01). Three logistic regression models could differentiate the two entities with a high degree of certainty (receiver operating characteristic area under the curve of 1.0). CONCLUSION: The study demonstrates the feasibility of distinguishing between microscopically similar inflammatory dermatoses using tissue-based molecular techniques.

Review: update on the management of calciphylaxis.

Calciphylaxis is a disease of significant morbidity and mortality, predominantly affecting dialysis patients. The term 'calciphylaxis' was coined by Seyle et al. in 1961 to describe calcium deposition in the skin and subcutaneous soft tissue of uremic rats in response to 'triggers' (e.g. trauma, metallic salts) after exposure to 'sensitizing agents' (e.g. vitamin D and parathyroid hormone). In humans, calciphylaxis, however, is not a disorder of induced hypersensitivity. Instead, it is a disorder of cutaneous microvascular occlusion caused by thrombosis and calcification. Progressive, excruciatingly painful, non-healing wounds develop in these patients, pre-disposing them to high risk of sepsis and death. Calciphylaxis has no approved therapies. Increased awareness and research in this field have facilitated identification of risk factors and causation pathways. Development of therapeutic options and wound care management, however, are still at a nascent stage. Certain therapies have shown a promise that needs evaluation in prospective clinical trials. It is hoped that ongoing research will help us better understand the pathogenesis of this complex disease and develop efficacious treatment options. In this review, we outline the components involved in calciphylaxis diagnosis and treatment.

Underreported use of palliative care and patient-reported outcome measures to address reduced quality of life in patients with calciphylaxis: a systematic review.

Calciphylaxis is associated with significant morbidity and mortality. Palliative care (PC) is a subspecialty that treats the pain and stress of serious illness. To assess whether the role of quality of life (QoL) indices, patient-reported outcome measures and PC have been studied in patients with calciphylaxis, we performed a systematic literature review. Several databases were searched from inception to October 2016 according to modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. We searched for papers on calciphylaxis that mentioned the symptoms and supportive needs of patients, QoL or outcome measures to report symptom severity, and the involvement of PC. Twelve papers met the inclusion criteria. Reported patient symptoms included pain, skin lesion resolution and pruritus, with the first being the most frequently reported. Four papers measured pain using a previously verified patient-reported outcome measure, including the Visual Analogue Scale. One paper used a verified QoL measure, the Dermatology Quality of Life Index. No tool was used consistently. Eight papers reported the use of hospice care or PC in the treatment of calciphylaxis. No outcome measure was used to prompt PC involvement. Overall, QoL indices, patient-reported outcome measures and PC are underreported in the treatment of calciphylaxis. PC may be a resource to assist in symptom management and adaptive coping strategies for patients from the onset of disease.

Voriconazole exposure and the risk of cutaneous squamous cell carcinoma in allogeneic hematopoietic stem cell transplant patients.

BACKGROUND: Voriconazole is a commonly used antifungal medication in allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients. In solid organ transplantation, voriconazole use has been associated with the development of cutaneous squamous cell carcinoma (SCC). We sought to determine if voriconazole use was associated with SCC in patients undergoing allo-HSCT. METHODS: We retrospectively reviewed consecutive adult patients who underwent allo-HSCT at Mayo Clinic from January 2007 through July 2012. Multivariable Cox models were created to assess the relationship of SCC with two time-dependent voriconazole exposure variables: (i) history of voriconazole exposure (yes/no), and (ii) cumulative days of voriconazole use. RESULTS: In our cohort of 381 allo-HSCT patients, SCC developed in 26 of 312 patients exposed to voriconazole (25 post-voriconazole) and in 1 of 69 patients who received alternative antifungal agent(s). Cumulative incidence of SCC was estimated to be 19% at 5 years post allo-transplant. Cumulative days of voriconazole use was found to be a risk factor for SCC, and this relationship persisted in a multivariable model using previously identified risk factors as covariates (hazard ratio 1.859 for each 180 days of use, P < 0.001). CONCLUSION: This is the first study, to our knowledge, to identify cumulative days of voriconazole use as a risk factor for SCC development following allo-HSCT, and may help guide appropriate antifungal use in this patient population.

Experience with the dermatology inpatient hospital service for adults: Mayo Clinic, 2000-2010.

BACKGROUND: There is a paucity of medical literature describing the role of dermatology inpatient hospital services for patients with severe dermatologic disease. A diminishing number of US hospitals have a dedicated dermatology inpatient service run by dermatologists. OBJECTIVES: To describe the role of a dermatology-run inpatient service in treatment of severe dermatologic disease from 2000 to 2010 at our institution. METHODS: We studied demographic characteristics, indications for admission and length of stay for the adult (age, >18 years) dermatology inpatient hospital service over the most recent decade. We compared data from the first 5.5 years with the subsequent 5.5 years and with previously published data. RESULTS: A total of 1732 patients had 2216 inpatient admissions to the adult service from 2000 to 2010. The mean (SD) age was 61.3 (17.7) years (age range 18-100 years). Median duration of admission was 3 days interquartile range (IQR), 2-5 days. The most common indications for admission were dermatitis (44.2%), psoriasis (17.4%) and cutaneous T-cell lymphoma (9.2%). We compared admissions from 2000 to mid-2005 (n = 1260) to admissions from mid-2005 to 2010 (n = 956). Statistically significant changes included median length of stay (decreased from 4 days [IQR, 3-6 days] to 3 days [IQR, 2-4 days] P < 0.01), admissions for psoriasis (decreased from 20.7% to 13.0%; P < .01) and admissions for dermatitis (increased from 41.6% to 47.6%; P < .01). CONCLUSION: The number of patients admitted and the median length of stay decreased between the 2 periods. Indications for admission have changed significantly across the two time periods.

Cutaneous T-cell lymphoma and atopy: is there an association?

BACKGROUND: Case reports have suggested a relationship between atopic diatheses and Sézary syndrome, pre-Sézary syndrome or mycosis fungoides. However, Sézary and pre-Sézary syndromes are rare entities, and this association has never been analysed in greater detail for specific subtypes of cutaneous T-cell lymphoma (CTCL). OBJECTIVES: To evaluate the prevalence of atopy in subjects with Sézary syndrome, pre-Sézary syndrome or mycosis fungoides, and to compare the rates with the reported prevalence of atopy in the general population. METHODS: We retrospectively reviewed the records of 157 patients with the diagnosis of Sézary or pre-Sézary syndrome seen between 1965 and 2000, and 102 patients with the diagnosis of mycosis fungoides evaluated from 1994 to 2000 at Mayo Clinic. RESULTS: Of 157 subjects with Sézary or pre-Sézary syndrome and 102 subjects with mycosis fungoides, 18 and 12, respectively, were identified as having a history of atopic dermatitis, asthma or allergic rhinitis. The prevalence rates of atopy in Sézary or pre-Sézary syndrome and mycosis fungoides were 11.5% (95% confidence interval 6.9-17.5%) and 11.8% (6.2-19.7%), respectively. CONCLUSIONS: No significant difference exists in the prevalence of atopy in Sézary or pre-Sézary syndrome compared with that in mycosis fungoides (chi2-test, P = 1.00). Furthermore, the rates of atopy in Sézary or pre-Sézary syndrome and mycosis fungoides are not significantly different from the prevalence of atopy in the general population (17-40%). On the basis of these observations, no evidence currently implicates a causal association of CTCL with atopy.

Sporotrichosis masquerading as pyoderma gangrenosum: case report and review of 19 cases of sporotrichosis.

We present the case of a 59-year-old woman who had large ulcerations on her right leg that were diagnosed initially as pyoderma gangrenosum and treated with three immunosuppressive agents (cyclosporin, prednisone and azathioprine) for 6 months. Results of a biopsy at 6 months showed numerous cigar-shaped bodies consistent with Sporothrix schenckii; identification was confirmed by tissue culture. A retrospective review was performed for all cases diagnosed as sporotrichosis from tissue culture or biopsy specimens at the Mayo Clinic. Nineteen cases were identified. The present case was the only one in which fungal organisms were visible on histological examination. The present case emphasizes the importance of making a definitive histological diagnosis in unusual ulcer cases or in suspected cases of pyoderma gangrenosum before the initiation of immunosuppressive therapy. The large number of cigar-shaped bodies in the tissue is a rare finding in sporothrix infection and has been reported in only two cases previously.

Contact Allergen Avoidance Program: a topical skin care product database.

Management of allergic contact dermatitis can be challenging for patients because of difficulties they encounter while attempting to avoid antigens identified by patch tests. The disorder is commonly caused by fragrances, preservatives, or other ingredients found in skin care products. After patch testing, the clinician routinely educates the patient on the sources of the antigens to which he or she is sensitive. Because typical allergen names are long, are difficult to spell, commonly have numerous complex synonyms, and are often frankly intimidating for patients, compliance with allergen avoidance is frequently problematic. We have developed a Contact Allergen Avoidance Program database tool that generates an extensive list of skin care products that are free of the given patient's allergens. It has been used clinically for 2 years to facilitate successful antigen avoidance and has been positively received by both patients and clinicians.

Relevant contact sensitivities in patients with the diagnosis of oral lichen planus.

BACKGROUND: The concept of contact allergy aggravating or inducing oral lichenoid mucositis diagnosed as oral lichen planus (OLP) is well recognized but somewhat controversial. OBJECTIVE: We sought to identify clinically relevant contact allergens that may be important in the management of patients with OLP. METHODS: We retrospectively reviewed patients with OLP who had patch tests performed at Mayo Clinic Rochester and Mayo Clinic Scottsdale from 1994 to 1997 and 1988 to 1997, respectively. RESULTS: Patch tests were performed on 46 patients with a clinical and histopathologic diagnosis of OLP. Of these, 25 (54%) had positive patch test results. Eighteen (72%) of the patients with positive results had clinically relevant reactions. Of the patients with positive metal reactions, 5 had improvement after removal of the metal prosthesis or restoration. Six others noted that their most troublesome areas were adjacent to metal dental restorations. Six patients with reactions to flavorings and one patient with an acrylate dental retainer sensitivity had improvement after avoiding these allergens. CONCLUSION: Our findings support the concept that contact allergy to metals, flavorings, and plastics can be important in the pathogenesis and management of patients with oral lichenoid mucositis diagnosed as OLP.

The Arab Muslim client: implications for anesthesia.

The Arab Muslim client has unique cultural characteristics that should be incorporated into anesthetic care. In obtaining a preoperative assessment and consent, issues such as privacy, family roles, body language, group decision making, communication distances, and use of translators should be addressed. Intraoperatively, the need for modesty and the client's possible adherence to folk beliefs should also be recognized. Postoperatively, pain and overall needs assessments are a continuing challenge. The anesthetist must also understand the underlying family roles, the high correlation between fear and pain, and the possible coexisting folk beliefs when working within the labor and delivery setting. By addressing these unique issues, the anesthetist can provide appropriate and safe anesthetic care.

Polyarticular blastomycotic arthritis.

Blastomycotic arthritis usually presents as acute monoarticular septic arthritis resembling a bacterial process. Only 2 cases in the literature have subsequently developed arthritis in a second joint. We describe the case of an elderly woman with polyarticular blastomycotic arthritis associated with lung, skin, and bone involvement. The organism was identified in the synovial fluid and skin biopsies. Our patient underwent open drainage and aspiration of the involved joints and received antimycotic therapy.

Contact hypersensitivity to tixocortol pivalate.

BACKGROUND: Tixocortol pivalate is an established marker to topical corticosteroid allergy. The prevalence of tixocortol pivalate hypersensitivity is well established in Europe, where exposure to this corticosteroid as a therapeutic agent varies. In the United States, tixocortol pivalate is not commercially available and the prevalence of hypersensitivity to it is unknown. OBJECTIVE: We investigated the prevalence of tixocortol pivalate hypersensitivity in our patch-tested population. We further characterized these patients by clinical background, other contact allergens, and the reactivity to other corticosteroids. METHODS: Tixocortol pivalate has been incorporated in our standard 1-52 patch test series since November 1992. We reviewed the histories and patch test results in all patients tested with the standard 1-52 series from November 1992 to December 1996. RESULTS: Of 1536 patch-tested patients, 45 had hypersensitivity to tixocortol pivalate. Dermatitis involving the face was the most common (14 patients). Of the 45 patients, 40 had another allergen identified on patch testing. Eighteen patients underwent further patch testing to an extended corticosteroid panel, and 14 had sensitivity to another steroid agent. CONCLUSION: The 2.9% prevalence of tixocortol pivalate hypersensitivity in our patch test population is within the range reported in Europe. Patients with tixocortol pivalate hypersensitivity tend to have other contact allergens on patch testing. Predisposing factors to tixocortol pivalate hypersensitivity include facial dermatitis and sensitivity to other contact allergens.

Topical psoralen-ultraviolet A therapy for palmoplantar dermatoses: experience with 35 consecutive patients.

OBJECTIVE: To report the effectiveness of topical psoralen-ultraviolet A (PUVA) therapy for palmoplantar dermatoses and to describe our method of administration of this treatment modality. DESIGN: We conducted a retrospective study of 35 patients, 27 to 66 years of age, who received topical hand and foot PUVA therapy. MATERIAL AND METHODS: Ten patients had psoriasis vulgaris, 8 had pustular psoriasis, 5 had dyshidrotic eczema, and 12 had other types of dermatitis. The affected area was soaked in a psoralen solution, 0.0005% methoxsalen (10 mg of methoxsalen in 2 L of warm water), for 30 minutes and then exposed to incremental amounts of ultraviolet A light three times weekly until the dermatosis subsided or cleared. Treatment frequency was then reduced and ultimately discontinued. Time to maximal improvement of the hands and feet was defined as the period from the beginning of PUVA treatment to the point at which the frequency of treatment was reduced from three times weekly to twice weekly. RESULTS: Fourteen patients (40%) had clearing of their disease, and 14 others (40%) had improvement of their conditions. The mean time to clearing was 2.8 months (range, 2 weeks to 7 months), and the mean number of treatments was 27.3 (range, 10 to 55). The mean total dose of ultraviolet A received was 140 J/cm2 (range, 9 to 530). Two patients (6%) had no response to treatment. Mild localized ultraviolet-related erythema developed in 16 patients (46%). Five patients "dropped out" of treatment, and nine other patients discontinued treatment during maintenance therapy. The principal reason cited was inconvenience. CONCLUSION: Topical PUVA therapy is an effective and safe treatment option for recalcitrant dermatoses affecting the palms and soles.

Follicular mucinosis presenting as an acneiform eruption: report of four cases.

Follicular mucinosis can be a primary idiopathic disease or a secondary disease associated with lymphoma. When it appears in childhood or adolescence, it is usually primary and self-limited. We describe four cases of follicular mucinosis occurring in early adulthood that have had protracted courses. Each presented as an unusual acneiform eruption. Two of the cases demonstrated a clonal genetic rearrangement of the T-cell receptor within the cutaneous lymphoid infiltrate, a finding not previously reported. Although its significance is not clear, the clonal lymphocytic expansion indicates a need for continued surveillance of these patients.

Allergic contact dermatitis due to topical application of corticosteroids: review and clinical implications.

Allergy due to topically applied corticosteroids is being recognized more frequently. Testing for hypersensitivity to these agents is performed with delayed hypersensitivity patch testing. Cross-reactivity among topically administered corticosteroids is frequent and often can be predicted on the basis of additional patch testing and an established classification scheme. Herein we review allergy due to topically applied corticosteroids with regard to its prevalence, means of testing, cross-reactivity among the subclasses, risk factors, and relationship to steroids.

Granulomatous vasculitis associated with herpes virus: a persistent, painful, postherpetic papular eruption.

Cutaneous granulomatous vasculitis manifesting as a postherpetic reaction pattern is uncommon hand has previously been reported as a delayed complication of varicella-zoster virus infection. We describe three patients who had persistent, painful, postherpetic papules in a zosteriform distribution that histologically demonstrated a small vessel granulomatous vasculitis. Herpes simplex virus DNA detected by the polymerase chain reaction technique was demonstrated in two cases.