Surgical corner. Modified buried suture technique for the scalp.

Large surgical defects on an actinically damaged scalp are notoriously difficult to close primarily. Not only is the skin weak and friable, but the underlying bone often limits the size of "bite" that the surgeon can take with their deep suture. We describe a technique that maximizes the ability to grasp adequate deep tissue with the suture, decreasing the likelihood of tearing through the tissue when the wound edges are brought together.

Acute mucocutaneous methotrexate toxicity associated with interface dermatitis and numerous eosinophils.

Acute mucocutaneous methotrexate toxicity is not classically associated with prominent tissue eosinophilia. We present a case of acute methotrexate toxicity associated with pancytopenia and mucocutaneous erosion with interface dermatitis and numerous eosinophils. A 79-year-old male, with a history of psoriasis vulgaris on methotrexate therapy, presented with blisters of the oral mucosa, groin, sacrum, and extremities after daily consumption of methotrexate. Examination revealed blisters and erosions localized to psoriatic plaques, the perineum, and the oral mucosa. Laboratory evaluation demonstrated pancytopenia, megaloblastic anemia, and elevated liver function tests. A skin biopsy of an eroded plaque revealed psoriasiform epidermal hyperplasia with epidermal erosion, parakeratosis, and loss of the granular cell layer. There was an underlying band-like lymphoid infiltrate with interface dermatitis, dyskeratotic keratinocytes, and numerous eosinophils. Direct immunofluorescence studies were negative for the deposition of immunoreactants. Methotrexate was held, and the patient received leucovorin resulting in improvement of blood counts and cutaneous lesions. The histopathologic changes associated with acute mucocutaneous toxicity have been described as pauci-inflammatory erosions associated with dyskeratotic keratinocytes to interface dermatitis with necrotic keratinocytes and occasionally associated eosinophils. Although these changes are most often superimposed on psoriatic plaques, they have been reported to occur on normal skin. Therefore, the differential diagnosis may include lichen planus, a lichenoid drug eruption, or a fixed drug eruption, and given the presence of mucosal ulceration, incipient pemphigus vulgaris or paraneoplastic pemphigus vulgaris. This case illustrates that acute mucocutaneous methotrexate toxicity may be associated with both interface dermatitis and numerous eosinophils.

PAS is optimal for diagnosing onychomycosis.

Onychomycosis is a frequently treated fungal infection of the nail plate with morbidity in high-risk populations. The diagnosis often relies on histopathologic analysis of nail plate specimens with the assistance of special stains. Pathologists utilize periodic acid schiff (PAS) and/or Gomori methenamine silver (GMS) stains to highlight fungi within the nail plate. In a recent study of 51 PAS-negative nail cases, it was concluded that GMS is superior to PAS in the diagnosis of onychomycosis. We expand on this study by investigating a larger number of PAS-negative nail clippings determining whether GMS or PAS is superior in highlighting fungi in additional sections. There was no difference in the sensitivity of PAS vs. GMS (4.2 vs. 4.3%, p = 0.57); however, PAS was found to be significantly less expensive by 2.6-fold. Taken together, these data suggest that the PAS stain is the optimal method for diagnosing onychomycosis.

A current review of juvenile pemphigus vulgaris: analysis of data on clinical outcomes.

Forty-seven cases of juvenile pemphigus vulgaris have been reported in the English literature. Histology of lesional skin and direct immunofluorescence of perilesional skin are both necessary for a complete diagnosis. The autoimmune bullous condition can affect the skin and mucous membranes individually, but typically affects both concurrently. Disease characteristics in juvenile patients are similar to those in adults; however, a disruption of biologic and social development is of particular concern during adolescence. Although systemic corticosteroids have been used to successfully treat the disease in most cases, long-term use is often necessary for adequate control. Adverse effects from therapy can have devastating effects during this critical period of hormonal changes, physical and mental growth, and social and cultural development that occurs during adolescence. Newer therapies must be designed to adequately treat juvenile patients while also limiting serious adverse effects.

Patch-testing while on systemic immunosuppressants.

BACKGROUND: Occasionally, the need arises to patch-test patients while they are on immunomodulators. Little is known about how these systemic agents affect the results of patch testing. OBJECTIVE: To present data on 11 patients who underwent patch testing while under the effects of immunosuppressants. METHODS: Retrospective chart reviews were performed on 11 patients who underwent patch testing while they were taking various systemic immunosuppressants or within 48 hours of cessation of various systemic immunosuppressants. RESULTS: Patients had been taking prednisone (n = 6), cyclosporine (n = 2), combination cyclosporine and prednisone (n = 1), mycophenolate mofetil (n = 1), and infliximab (n = 1) up to 48 hours prior to and/or during patch testing. Seven patients showed at least one strong (++) or extreme (+++) patch-test reaction. Three patients had at least one weak (+) reaction. One patient showed only questionable reactions. The patient on mycophenolate was eventually retested while off immunosuppressants and showed strong clinically relevant patch-test reactions. Overall, 8 of the 11 patients reported some improvement in their dermatitis, including all the patients with strong or extreme reactions. CONCLUSION: While it is optimal for patch testing to be performed when patients are off immunosuppressants, immunosuppressive therapies should not be an absolute contraindication to patch testing.

Cutaneous disseminated xanthogranuloma in an adult: case report and review of the literature.

Xanthogranuloma (XG) is a rare, non-Langerhans cell histiocytosis (LCH) that most commonly presents in infancy or early childhood. The condition is typified by the formation of reddish to yellow papules and nodules that are usually solitary. Xanthogranuloma rarely occurs in adults with immunohistochemical features similar to those seen in juvenile XG. Lesions in the adult form seen in juvenile XG. Lesions in the adult form also are typically solitary. We describe a 70-year-old white man who presented with widespread flat-topped, reddish to yellow papules and nodules with histologic and immunohistochemical findings consistent with XG. We explore the pathogenesis, differential diagnosis, prognosis, and treatment of this rare eruption. Comparison of adult and juvenile XG will facilitate a better understanding of the disease. Although rare, XG is an important disease to consider in the differential diagnosis of xanthomatous disease in adults.

Lichen planus-like eruptions: an emerging side effect of tumor necrosis factor-alpha antagonists.

As tumor necrosis factor (TNF)-alpha inhibitors gain wider use in clinical practice, it is becoming increasingly evident that these potent immunosuppressants can also induce inflammatory reactions. We present two cases of lichen planus-like eruptions after infliximab and adalimumab therapy for psoriasis, and review the literature on this phenomenon. Eleven cases of lichen planus or lichenoid drug eruptions have been previously reported in patients taking TNF-alpha inhibitors, in addition to several cases of psoriasiform eruptions with a lichenoid histology. Because TNF-alpha has been implicated in the pathogenesis of lichen planus, induction of lichenoid reactions by TNF-alpha inhibition is somewhat unexpected. We consider potential immunologic mechanisms, and suggest that TNF-alpha inhibition may precipitate lichenoid reactions through disruption of a delicate balance between TNF-alpha and interferon-alpha in susceptible patients.

Treatment of juvenile pemphigus vulgaris with intravenous immunoglobulin therapy.

We report the clinical response and follow-up on eight patients with juvenile pemphigus vulgaris treated with intravenous immunoglobulin. Six Caucasian females and two Caucasian males ages 15 to 18 (mean 15.5) were treated with intravenous immunoglobulin based on a published protocol. The indications were lack of response and development of serious side-effects to conventional therapy in four, lack of response to dapsone in two, and parental choice in two patients. In seven patients, a prolonged clinical remission was achieved. They received a mean of 28.5 cycles of intravenous immunoglobulin in a mean of 43.4 months and were followed for a mean of 29.8 months after discontinuing treatment. The remaining patient responded, but was lost to follow-up. Mean follow-up was 71.7 months. Six patients experienced mild headache, but no serious side-effects were observed in any patient. Intravenous immunoglobulin is a safe biological agent to use in the treatment of juvenile pemphigus vulgaris. It can be used as monotherapy and has the potential to induce and sustain long-term clinical remissions. In these eight patients, it appears that intravenous immunoglobulin is a safe biological agent without serious, immediate, or long-term side effects. Intravenous immunoglobulin is a valuable agent in the treatment of certain cases of juvenile pemphigus vulgaris.

Survey research in dermatology: guidelines for success.

Survey research has been used to investigate a wide range of issues in dermatology. The proper use of survey design and analysis is critical for achieving reliable, accurate data and high impact in the medical literature. Here we describe the use of surveys from both a theoretical and practical standpoint. We provide recommendations for limiting error and producing interpretable results, followed by an outline for achieving publication. We conclude with a discussion of previous successful uses of survey studies in dermatologic literature.

Th17 cells: a new therapeutic target in inflammatory dermatoses.

Th17 cells, named for their secretion of interleukin-17 (IL-17), are a new class of T-cells involved in a wide range of cutaneous autoimmune and inflammatory conditions. An overactive Th17 cell response in the skin can produce damaging results. There appears to be a partial role for the Th17 axis in the pathogenesis of a range of dermatological diseases including allergic contact dermatitis, atopic dermatitis, psoriasis, and scleroderma. Immunologists have also discovered a unique association between Th17 cells and cutaneous T-cell lymphoma. The Th17 branch has been linked to a number of additional systemic inflammatory diseases with significant cutaneous pathology such as systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, and Behcet's disease. Newly developed treatment modalities for neutralizing the Th17 branch of the immune system are proving to be valuable additions to the current therapeutic armamentarium.

Th17 cells: a new paradigm for cutaneous inflammation.

Inflammatory processes of the skin have classically been segregated to either the cell-mediated, T-helper type 1 (Th1) or the humoral (Th2) branch of the immune system. The recent addition of Th17 cells, a novel T-helper cell named for its secretion of interleukin (IL)-17, to current thinking in autoimmunity has resulted in a significant paradigm shift in immunological thinking. Collectively, Th17 cytokines have been found to stimulate cutaneous immune reactions through an activation of a wide range of downstream inflammatory mediators and an induction of immune cell and keratinocyte proliferation as well as angiogenesis. Newly developed treatment modalities for neutralizing the Th17 branch of the immune system are proving to be valuable additions to the current therapeutic armamentarium. Here we describe a new schema for dermatologic T-cell-mediated immunity. We elucidate experiments confirming the presence of Th17 cells, followed by a discussion of their relevance to cutaneous inflammation and psoriasis.

Photoprotection in human skin--a multifaceted SOS response.

Human skin has developed elaborate defense mechanisms for combating a wide variety of potentially damaging environmental factors; principal among these is UV light. Despite these defenses, short-term damage may include painful sunburn and long-term UV damage results in both accelerated skin aging and skin cancers such as basal cell carcinoma, squamous cell carcinoma and even malignant melanoma. While UV radiation damages many cellular constituents, its most lasting effects involve DNA alteration. The following sections briefly review UV-inducible protective responses in bacteria and in skin, thymidine dinucleotides (pTT) as a powerful probe of DNA damage responses, and potential means of harnessing these inducible responses therapeutically to reduce the now enormous burden of cutaneous photodamage in our society.

Sorbitan sesquioleate, a common emulsifier in topical corticosteroids, is an important contact allergen.

BACKGROUND: In the past, sorbitan sesquioleate (SSO) was reported as an uncommon allergen, but recent data suggest SSO may be an important sensitizer. OBJECTIVE: To present data on 13 of 112 dermatitis patients who reacted to SSO and/or sorbitan monooleate (SMO) on patch testing. METHODS: A retrospective data analysis was conducted on data from 112 dermatitis patients patch-tested from December 2006 to May 2007. All patients were tested with a modified North American Contact Dermatitis Group standard series, a cosmetic series, and a fragrance series. RESULTS: Of 112 patients, 10 (8.9%) reacted to SSO, 1 (0.9%) to SMO, and 2 (1.8%) to both. Nine of 12 (75%) SSO-positive patients were using topical corticosteroids emulsified with sorbitan derivatives or sorbitol; 2 of the 13 sorbitan-allergic patients were allergic to one or more corticosteroid screening chemicals tested. CONCLUSION: SSO is a common emulsifier derived from sorbitol and is used in many high- to super-potent corticosteroids. It has only recently been identified as an important contact allergen. The high prevalence of reactions to sorbitol derivatives in this small group of patients suggests that these chemicals may be sensitizing when applied to dermatitic skin. Larger studies should be conducted to confirm these findings.

Sorbitan sesquioleate: an emerging contact allergen.

Sorbitol-based emulsifiers such as sorbitan sesquioleate (SSO) are commonly used in topical corticosteroids, topical antibiotics, topical antifungals, moisturizing creams and lotions, and topical retinoids. Contact dermatitis from sorbitol derivatives appears to be increasingly prevalent. Patch-testing with SSO can be useful in the work-up of patients with presumptive cosmetic allergic contact dermatitis. Those sensitized to SSO can be counseled to avoid sorbitol-containing products, especially topical corticosteroids. Herein we discuss case reports of SSO allergy and a recent case series of 12 of 112 dermatitis patients (10.7%) patch-tested during a 6-month period who showed contact allergy to SSO. We provide a list of key corticosteroids and products that can contain SSO, sorbitol, or sorbitol derivatives.