iPLEDGE Must Abstain from Abstinence.

Isotretinoin has unmatched efficacy in the treatment of acne. However, because isotretinoin is a teratogen that can cause profound birth defects, the iPLEDGE program regulates the drug's distribution in the United States. To minimize fetal exposure to isotretinoin, the program requires that female patients capable of becoming pregnant use two forms of contraception or commit to abstinence while using this therapy. This manuscript argues that iPLEDGE should be revised to remove abstinence as an acceptable contraceptive option in the face of evidence that disputes its efficacy. All patients, regardless of reported sexual activity, should be required to use data-proven contraception. Potential benefits of the proposed change (iPLEDGE-R) include reducing the number of isotretinoin pregnancies, increasing patient privacy protection, and standardizing patient care. Further investigation needs to guide additional strategies to achieve the program's public health goal; however, the ethical and pragmatic advantages of iPLEDGE-R merit consideration.

Dog walking can be hazardous to cutaneous health.

Dog walking has been widely promoted by the medical profession for its potential health benefits, especially among older individuals. However, this activity has a less well-recognized risk for notable cutaneous, osseous, and even neurologic trauma. We chronicle 5 cases of dog walking gone awry, leading to minor to massive cutaneous trauma, as a precaution for providers who heartily endorse this seemingly benign pastime.

Probable African Tick Bite Fever in the United States.

African tick bite fever (ATBF) is a tick-borne rickettsial disease most often observed in North American and European tourists returning home from the southern portion of Africa. Ticks infected with Rickettsia africae transmit this parasitic bacterium to humans, who subsequently develop an influenza-like illness, one or more inoculation eschars, and in some cases, a cutaneous rash. Because ATBF often presents with non-specific symptoms that suggest other infectious diseases, establishing the diagnosis may be difficult. Confirmatory assays, including serology and nucleic acid amplification, may take weeks to return and cannot help with acute treatment decisions. We present a case of a previously healthy 60-year-old woman who developed an illness strongly suggestive of ATBF after a missionary trip to Zimbabwe and discuss the disease's diagnostic challenges. Our paper also reviews the epidemiology of this disease and the currently available diagnostic laboratory tests and recommended treatment options.

A case of streptococcal surgical site infection following Mohs surgery.

Group A ß-hemolytic Streptococcal (GAS) cellulitis is an uncommon surgical site infection that presents with rapid onset of pain and swelling in the first few days after a procedure. Unlike staphylococcal cellulitis, GAS cellulitis lacks purulence and spreading erythema. The absence of these classic signs may delay the diagnosis of GAS cellulitis and lead to severe complications. We present the case of an immunosuppressed 49-year-old patient who developed swelling and severe pain at his incision site two days after undergoing Mohs micrographic surgery on his forehead. He was clinically diagnosed with GAS cellulitis and recovered with intravenous antibiotics. Unfortunately, there is a paucity of information about GAS cellulitis in the dermatologic literature and clinicians need to recognize and aggressively treat this rare but serious complication of Mohs micrographic surgery.

Superficial Basal Cell Carcinoma of the Face Successfully Treated with Ingenol Mebutate 0.05% Gel: Case Report and a Review of the Literature.

A 64 year-old Caucasian male patient with a long history of ultraviolet light exposure and multiple actinic keratoses presented with a large, erythematous, and scaly plaque on his forehead. Biopsies revealed superficial basal cell carcinoma (sBCC). Because the patient wanted the shortest possible topical regimen, his sBCC was treated with two overnight ingenol mebutate (IM) 0.05% gel applications. He tolerated the local skin reaction (LSR) well, and at approximately six weeks post-treatment, biopsies showed no evidence of sBCC. The patient was happy with the cosmetic outcome and has remained free of clinical recurrence for 18 months. Although IM gel is only FDA approved for the treatment of actinic keratosis, it has also been used off-label to treat other epithelial lesions, including basal cell carcinoma (BCC), anogenital warts, and Bowen's disease. One clinical trial, multiple case series and case reports, and now this report, have demonstrated IM's utility in treating BCC. IM treatment is therefore a promising alternative to surgery for select BCC, with major advantages, including a short treatment duration and generally favorable cosmetic outcome.