A simple technique to reconstruct medium to large scalp defects with exposed bone.

Medium to large scalp defects with exposed bone can pose particular challenges to the dermatologic surgeon. Most of the publications pertaining to the repair of such defects are presented in the plastic surgery literature. Dermatologic surgeons may have less experience in this area and be hesitant to pursue surgery when these defects may be encountered. The technique described below is a simple, one-stage reconstruction, with a short healing period, providing adequate cosmesis, and is within the capability of most dermatologic surgeons.

Histological Features of Flagellate Erythema.

Flagellate erythema is a distinctive eruption characterized by "whip-like" linear or curvilinear streaks and plaques, occurring mainly on the trunk. It has classically been described in 2 disparate clinical settings: chemotherapy with bleomycin and ingestion of mushrooms (most commonly Shiitake mushrooms). Most of the literature comprises single case reports, often with minimal histological description of rather nonspecific features. We describe in detail the histological features of 3 cases of flagellate erythema (2 related to bleomycin therapy and one related to ingestion of mushrooms) and review the findings described in the literature to define the spectrum of histological changes encountered in this eruption. Our 3 cases showed mild epidermal changes, with spongiosis and variable interface inflammation. All 3 showed a relatively prominent dermal lymphohistiocytic infiltrate, with features suggestive of a lymphocytic vasculopathy extending to at least the mid-reticular dermis. Eosinophils were a prominent component of the inflammatory infiltrate in 2 cases. Our review of the literature identified a total of 45 publications, representing reports of 46 patients, containing histological information. As well as bleomycin- and mushroom-related cases, similar eruptions have been reported in the context of connective tissue disease and other drugs. Although cases related to connective tissue disease show features of the underlying condition, cases secondary to drugs or mushrooms predominantly show features compatible with common patterns of exanthematous/morbilliform drug reaction. In particular, subtle spongiosis and/or interface dermatitis combined with a dermal lymphocytic infiltrate that includes increased numbers of eosinophils is a common finding. Features of a lymphocytic vasculopathy may be seen in a subset of these cases.

Dental patch testing in patients with undifferentiated oral lichen planus.

BACKGROUND/OBJECTIVES: Distinguishing between oral lichen planus (LP) and lichenoid reactions to dental restorations can be impossible on clinical and histopathological grounds. Epicutaneous patch testing is an investigation that may guide patients and physicians in making timely and costly decisions to replace or cover existing dental restorations. This study aimed to assess the role of epicutaneous patch testing with a battery of dental allergens in patients with undifferentiated oral LP. METHODS: A retrospective review of the medical records of patients with biopsy-proven oral LP referred by an oral medicine specialist and who presented for dental epicutaneous patch testing at a dermatology clinic in Perth, Western Australia between 2009 and 2016 was performed. RESULTS: In total, 68 patients were included, of whom 54 (79%) had positive patch tests. Gold 26 (48%), mercury 24 (44%), nickel 22 (41%), copper 19 (35%), potassium dichromate 14 (26%) and methylhydroquinone 13 (24%) were the most common allergens for which patients tested positive. Hypothyroidism and non-steroidal anti-inflammatory drugs were associated with negative patch tests (P = 0.01 and 0.04, respectively). Smoking history, other medications and comorbidities, the location of the dental restorations and unilateral or bilateral disease were not significantly associated with the patch test results. Restorations were removed in 23 patients: 21 of these (91%) had positive epicutaneous patch tests. Of the 20 patients followed up, 19 (95%) experienced some improvement, among whom 11 (58%) had complete remission. CONCLUSION: Epicutaneous patch testing disclosed a high proportion of relevant positives. This guided the clinical decision to change dental restorations, with high rate of clinical improvement.

Pseudomelanomas Following Stevens-Johnson Syndrome.

In this report, we present a novel case of pseudomelanoma, similar to that seen in a recurrent/traumatized nevus, in pre-existing nevi in a 36-year-old man a few months after recovering from an episode of severe Stevens-Johnson syndrome. The mechanism responsible for the atypical transformation of these nevi is likely the release of cytokines and growth factors in the microenvironment during the repair/regeneration process. It is important to be aware of this phenomenon, and specific inquiry about potential recent blistering skin disorder in addition to the other causes of trauma should be made when dealing with cases of pseudomelanoma to avoid misdiagnosis.

A case of abatacept associated neutrophilic dermatosis and a review of the literature.

Abatacept is a novel biological agent that dampens the immune response by blocking the co-stimulation of T-cells, thus downregulating T-cell activation. It is currently approved for the treatment of rheumatoid arthritis (RA). The group of novel immunomodulatory agents, referred to as biologics, have now been used extensively, with established safety and side-effect profiles. There are, however, increasing reports of adverse paradoxical reactions, most notably resulting from anti-tumour necrosis factor (TNF) therapy. While cutaneous adverse reactions to abatacept are rare, there are a few reports of such paradoxical reactions. We report a case of an idiosyncratic paradoxical neutrophilic dermatosis associated with the use of abatacept.