Poorly differentiated carcinoma arising in the setting of erythema ab igne.

Erythema ab igne (EAI) is a reticulated, erythematous, or hyperpigmented dermatosis that is caused by chronic exposure to infrared radiation. Chronic lesions of EAI have significant potential for malignant transformation. We report a case of poorly differentiated carcinoma arising within a patch of long-standing EAI on the lower extremity of a 92-year-old female. This case highlights the importance of recognizing EAI early and counseling patients to avoid further exposure to the offending infrared source to reduce the risk of malignant transformation. EAI has been associated with several different types of cutaneous neoplasms including the Merkel cell carcinoma, squamous cell carcinoma, and cutaneous marginal zone lymphoma.

Adjunctive radiotherapy in the treatment of cutaneous squamous cell carcinoma with perineural invasion.

Perineural invasion is a feature associated with significantly poorer outcomes when present in cutaneous squamous cell carcinoma (CSCC). The incidence of this subset of CSCC continues to rise in the US, as does the confusion surrounding exactly how it should be managed. While management typically involves excision, considerable debate exists as to the appropriate use of adjuvant radiotherapy (ART) in addition to excision. This article reviews the current relevant evidence for the use of ART.

Bullosis diabeticorum associated with a prediabetic state.

Bullosis diabeticorum, or diabetic bullae, is a non-inflammatory blistering condition that is virtually diagnostic of diabetes. Diabetic bullae most often present as painless, tense, superficial bullae that occur in an acral distribution and commonly heal in 2-6 weeks without scarring, but complications such as secondary bacterial infection or hemorrhage may occur. The diagnosis of bullosis diabeticorum in a nondiabetic patient should prompt screening for diabetes. A case of recurrent bullae in a prediabetic patient is presented, with a review of the clinical features and significance of bullosis diabeticorum.

Calcitriol ointment: a review of a topical vitamin D analog for psoriasis.

Topical vitamin D analogs are a safe and effective treatment for psoriasis vulgaris. This is a brief review of calcitriol 3 microg/g ointment in the treatment of psoriasis. Calcitriol has been safely used outside the USA in Europe under the trade name Silkis Ointment for almost a decade in the treatment of psoriasis, and it is currently FDA-approved as Vectical Ointment. Calcitriol 3 microg/g ointment is a synthetic topical vitamin D analog considered to be as effective as other vitamin D analogs but with a better tolerability in sensitive areas.

Urticarial vasculitis: a unique presentation.

Urticarial vasculitis is a relatively rare diagnosis in a patient presenting with urticaria. The process is classically described as a generalized eruption, painful more so than pruritic, lasting longer than 24 hours. Two forms of urticarial vasculitis have been described: ahypocomplementemic form more commonly associated with systemic disease, and a normocomplementemic form that is generally limited to the skin. We report on a uniquely distributed vasculitic eruption restricted mainly to the anterior belt line area in a patient presenting with urticaria and intense pruritus. Urticarial vasculitis as a unique entity is reviewed along with its clinical and histopathologic presentation and the pharmacologic agents used for treatment.

X-linked agammaglobulinemia diagnosed late in life: case report and review of the literature.

BACKGROUND: Common variable immune deficiency (CVID), one of the most common primary immunodeficiency diseases presents in adults, whereas X-linked agammaglobulinemia (XLA), an inherited humoral immunodeficiency, is usually diagnosed early in life after maternal Igs have waned. However, there have been several reports in the world literature in which individuals have either had a delay in onset of symptoms or have been misdiagnosed with CVID and then later found to have mutations in Bruton's tyrosine kinase (BTK) yielding a reclassification as adult-onset variants of XLA. The typical finding of absent B cells should suggest XLA rather than CVID and may be a sensitive test to detect this condition, leading to the more specific test (Btk mutational analysis). Further confirmation may be by mutational analyses. METHODS: The records of 2 patients were reviewed and appropriate clinical data collected. BTK mutational analysis was carried out to investigate the suspicion of adult-presentation of XLA. A review of the world literature on delayed diagnosis of XLA and mild or "leaky" phenotype was performed. RESULTS: 2 patients previously diagnosed with CVID associated with virtual absence of CD19+ B cells were reclassified as having a delayed diagnosis and adult-presentation of XLA. Patient 1, a 64 yr old male with recurrent sinobronchial infections had a low level of serum IgG of 360 mg/dl (normal 736-1900), IgA <27 mg/dl (normal 90-474), and IgM <25 mg/dl (normal 50-415). Patient 2, a 46 yr old male with recurrent sinopulmonary infections had low IgG of 260 mg/dl, low IgA <16 mg/dl, and normal IgM. Mutational analysis of BTK was carried out in both patients and confirmed the diagnosis of XLA CONCLUSION: These two cases represent an unusual adult-presentation of XLA, a humoral immunodeficiency usually diagnosed in childhood and the need to further investigate a suspicion of XLA in adult males with CVID particularly those associated with low to absent CD19+ B cells. A diagnosis of XLA can have significant implications including family counseling, detecting female carriers, and early intervention and treatment of affected male descendents.

Increased frequency of large local reactions among systemic reactors during subcutaneous allergen immunotherapy.

BACKGROUND: Large local reactions are not uncommon during allergen immunotherapy (AIT). Dosage adjustments after large local reactions are commonly instituted despite literature that suggests individual large local reactions do not seem to predict subsequent systemic reactions. OBJECTIVE: To investigate the relationship between large local reactions and the risk of systemic reactions to AIT. METHODS: Retrospective review of the AIT database of a large, multicenter allergy practice group was conducted between June 1, 2003, and May 31, 2005. Numbers of large local reactions in 258 patients who experienced systemic reactions to AIT were compared with 299 age-, sex-, and sensitivity-matched control patients who did not experience systemic reactions during AIT. RESULTS: A total of 283 systemic reactions occurred in 258 patients during the surveillance period, which included 661,123 patient visits for 1,108,621 allergy injections. The systemic reaction rate was 0.043% of visits and 0.025% of injections. The large local reaction rate was 35.2% of visits and 19.5% of injections among systemic reactors compared with 8.9% of visits and 5.3% of injections in the controls (P < .001 each). Thus, the odds of experiencing large local reactions were significantly increased among systemic reactors. CONCLUSIONS: Although AIT is a safe and effective immunomodulatory therapeutic option for the treatment of allergic diseases, patients with increased frequency of large local reactions may have increased risk for future systemic reactions. Identifying additional risk factors remains viable. Recognizing the relevance of frequent large local reactions is important for designing safer protocols for successful AIT in these patients.