Smokeless tobacco keratosis.

Smokeless tobacco keratosis is a benign lesion characterized by the formation of white, gray, or pale macules or papules with wrinkling or rugae. It forms in the oral mucosa in response to the use of smokeless tobacco products. We present a 50-year-old man with an extensive history of smokeless tobacco use and development of the characteristic lesion. Shave biopsy showed typical changes of this benign condition and tobacco cessation was recommended.

What's Eating You? Caterpillars.

Caterpillar envenomation is a worldwide problem, with manifestations ranging from dermatitis to iridocyclitis and a fatal hemorrhagic diathesis. This article focuses on the diagnosis and management of dermatoses related to caterpillars.

Reliability of biopsy margin status for basal cell carcinoma: a retrospective study.

The reporting of biopsy margin status for basal cell carcinoma (BCC) varies among dermatopathologists. For biopsy specimens with seemingly negative margins, the question arises if the tumor extends beyond the margin in unexamined sections. We sought to determine the reliability of negative margin status for BCC and identify if any factors were predictive of positive true margins. We examined BCC biopsy specimens initially determined to have negative margins after routine sectioning and re-evaluated the margin status after complete tissue block sectioning of the initial biopsy specimen was performed. Our findings remind clinicians of the limitations of margin assessment and provide impetus for dermatopathologists to consider modifying how margin status is reported.

Impact of provider attire on patient satisfaction in an outpatient dermatology clinic.

Provider attire has been studied as a potential vector for infectious microorganisms in the medical setting as well as a potential factor in patient satisfaction. Our objective was to determine if a change from formal attire to fitted scrubs had a measurable impact on patient satisfaction scores in an outpatient dermatology setting. We designed a 2-year retrospective cohort study of 22 providers in an outpatient dermatology setting who transitioned from formal attire to fitted scrubs and had at least 12 months of patient satisfaction scores (measured by a third-party patient satisfaction survey) before and after the change in attire. The primary outcome was statistically significant change in patient satisfaction scores before and after the institution of fitted scrubs. A total of 3511 completed surveys were evaluated from the 12 months prior to the change in attire (study period 1), and 4191 completed surveys were evaluated in 12 months after the change (study period 2). No significant change was seen in the overall survey responses. A small but statistically significant improvement was noted for several questions in study period 2, which suggested that a change from formal attire to fitted scrubs did not have a strong impact on patient satisfaction scores. Factors beyond provider attire likely have the greatest impact on patient satisfaction.

Invasive penile squamous cell carcinoma.

Invasive penile squamous cell carcinoma (PSCC) is a rare malignancy with considerable morbidity and mortality. Because a delayed or incorrect diagnosis can have a devastating outcome, physicians should maintain a high index of clinical suspicion for PSCC in patients presenting with penile lesions, particularly in young or middle-aged patients in whom presentation of PSCC is uncommon. We report the case of a 27-year-old circumcised man who presented with invasive PSCC following a diagnosis of condyloma 8 years prior. The patient underwent robotic laparoscopic bilateral pelvis and inguinal lymph node dissection and re-excision of the primary PSCC, with one of 15 superficial right inguinal lymph nodes testing positive for squamous cell carcinoma. Given the patient's single-node positivity as well as the risks associated with chemotherapy with respect to his concurrent medical conditions, close follow-up with repeat imaging was planned following surgery. This case highlights the importance of biopsy in any lesion recalcitrant to conventional treatment modalities regardless of age. Early detection and treatment of PSCC can prevent organ dysfunction, loss of organ, or even death.

Acquired epidermodysplasia verruciformis occurring in a renal transplant recipient.

Acquired epidermodysplasia verruciformis (EDV) is a rare condition occurring in patients with depressed cellular immunity, particularly individuals with human immunodeficiency virus (HIV). Acquired EDV is less commonly reported in recipients of stem cell or solid organ transplantation. This condition typically manifests within 5 years of initial immunosuppression and can present as multiple hypopigmented to red, tinea versicolor-like macules or as multiple verrucous, flat-topped papules distributed over the trunk, arms, and legs. Human papillomavirus (HPV) types 5 and 8 are the most commonly isolated EDV-HPV subtypes as well as the most oncogenic subtypes, carrying the greatest risk for malignant transformation into squamous cell carcinoma (SCC). We present the case of a 44-year-old renal transplant recipient who developed multiple hypopigmented papules on the chest and neck with histopathology showing characteristic changes of EDV.

Eosinophils in mycosis fungoides: an uncommon finding in the patch and plaque stages.

Early diagnosis of mycosis fungoides (MF) is one of the most challenging problems in dermatopathology, as the histopathologic features of inflammatory dermatoses and MF may show significant overlap. One criterion used to distinguish early MF (patch stage) from dermatitis, which may be currently underutilized, is the presence of eosinophils. A search was performed for cases with a preoperative diagnosis of MF, cutaneous T-cell lymphoma, or dermatitis, which included 29 cases "diagnostic" for MF, 25 cases "suspicious" for MF, and 55 cases of spongiotic dermatitis. We examined tissue sections blinded to diagnosis to obtain an exact eosinophil count. Twenty-nine cases were diagnostic for MF (12 patch, 9 plaque, and 8 tumor stage). The average eosinophil count for cases diagnostic for patch stage MF was 1 eosinophil in 10 (0.11) sections examined. For plaque MF, there was 1 eosinophil in 5 (0.24) sections examined. All tumor stage MF cases showed abundant eosinophils within each section. Twenty-five cases were suspicious for MF (15 patches, 9 plaques, and 1 folliculotropic). The average eosinophil count for the patch lesions was 1 eosinophil in 4 (0.25) sections examined and 2 eosinophils per section for plaque lesions. Forty-five of 55 cases of spongiotic dermatitis had at least scattered eosinophils (>3) in each section. Twenty-three (47%) had eosinophils around most postcapillary venules. Only 3 of 45 patients (6.6%) with biopsies diagnostic or suspicious for patch or plaque stage MF showed >3 eosinophils per tissue section, whereas 45 of 55 (81.8%) biopsies of spongiotic dermatitis had >3. The presence of eosinophils (>3 per tissue section) is statistically significant in differentiating cases diagnostic or suspicious for patch or plaque stage MF from dermatitis (P < 0.0001). Our data indicate that eosinophils are uncommon in cases of patch and plaque MF. When a pathologist is faced with evaluating a biopsy that lacks some of the criteria used to make the diagnosis of patch stage MF, yet demonstrates >3 eosinophils per tissue section, dermatitis is the likely diagnosis. However, in cases where fewer than 3 eosinophils are present in sections, patch stage MF cannot be excluded.